Consent To Release Medical Informtion Template printable pdf download

CONSENT TO RELEASE MEDICAL INFORMTION

I give permission to __________________________________________________________________________

Entity

City/State

Zip

To release information from the medical record or disclose protected health information for:

_______________________________________________ ________________________ ________________

Patient Name

Social Security #

Birth Date

_______________________________________________ ________________________ ________________

Purpose of Disclosure

Date of Encounter/Visit

Daytime Phone #

Send Information to: Name: _________________________________________________________________

Address: _______________________________________________________________

Telephone # _______________________________Fax#__________________________

(include area code)

Circle one of the following choices to indicate the information to be disclosed:

1. A complete copy of my medical record regarding my treatment or care. (A fee may be charged)

2. Specific protected health information necessary for continued treatment or coordination for treatment.

Check those that apply: history & physical examination lab results x-ray reports

discharge summaryoperative report/procedure notepathology report

other (specify) __________________________________________________

I understand the protected health information to be disclosed may include information regarding

psychological or psychiatric impairment, substance abuse, Acquired Immunodeficiency Syndrome (AIDS), or

infection with Human Immunodeficiency Virus (HIV).

_________________________________________________________________ _______________________

Patient/Representative Signature

Date signed

_________________________________________________________________ ________________________

Representative’s relationship to patient

Witness

If you signed as a representative of the patient, read the following and sign below:

I,________________________________, hereby certify and attest that I am the duly authorized personal

representative of the above patient, and that I have the lawful authority to enter into this authorization on

behalf of such individual. I have read the provisions set forth in this authorization, and agree that the medical

record information of such individual for the purposes set forth herein.

_______________________________________________________ _________________________________

Signature

Date signed

Consent To Release Medical Informtion Template