Medical Release Of Information Form printable pdf download

MEDICAL RELEASE OF INFORMATION FORM

Patient Name:________________________________

Date of Birth:________________________

Social Security #:_____________________________

I request and authorize  Hospital/ER _______________________  Other specialist ____________________

 Primary care physician ________________

to release the medical records of the above named patient to:

Bailliard Henry Pediatric Cardiology PLLC

2304 Wesvill Court, Suite 320

Raleigh NC 27606

Fax 919 896 7494; Tel 919 890 5566

This request and authorization applies to: (initial either line 1 or 2)

1. ____All personal health information (PHI) relating to treatment from ___/___/___ to ___/___/___ :

This information may contain x-ray reports, laboratory reports, EKG reports, other diagnostic reports, consults, etc.

2. ____ The following PHI relating to treatment from ___/___/___ to ___/___/___ :

 History and Physical Examination

 Discharge Summary

 Labs, X-Ray, any diagnostic report

 Consult Notes

 Medication lists

 Operative reports

 Clinic notes

This request and authorization also applies to:

____All Health Care information relating to HIV/AIDS testing, sexually transmitted diseases, psychiatric disorders /

mental health or drug and/or alcohol use. (Please initial and circle all that apply)

I understand I have the right to revoke this authorization by providing a written request to do so to Bailliard Henry

Pediatric Cardiology, PLLC. I understand that the revocation will not apply to information that has already been released

and will take effect on the date that the request is received.

Unless otherwise revoked, this Authorization will expire twelve months from the date signed. I understand that

authorizing the disclosure of this health information is voluntary.

I understand that Bailliard Henry Pediatric Cardiology, PLLC assumes no responsibility for the use or misuse by others

of my health information disclosed under this authorization. I release Bailliard Henry Pediatric Cardiology, PLLC from

all legal liability that may arise from this authorization.

By signing this form, I authorize Bailliard Henry Pediatric Cardiology, PLLC to request and use the PHI described

above.

_______________________________________

_________________________________

Signature of Parent/Guardian/Adult Patient

Date

_______________________________________

Relationship to Patient

Medical Release Of Information Form