Fillable Patient Authorization To Obtain Outside Medical Records Form printable pdf download

Patient Authorization To Obtain Outside Medical Records Form

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Harbin Clinic – Patient Authorization To Obtain Outside Medical Records

Patient Name: ___________________________________ Social Security Number: _________________

Previous Name, if applicable: ____________________________ Date of Birth: __________________

Address: ____________________________City: ______________________ State: _______Zip ____________

Home Phone: ____________________

Work Phone: ________________________

I authorize Harbin Clinic provider _________________________________to obtain all or part of my medical

record which may include treatment for drug abuse, child abuse, AIDS, alcoholism or mental illness.

My records need to be obtained from the following Doctor/Facility:

Name:___________________________________

Name:____________________________________

Address__________________________________

Address __________________________________

City __________________State _____ Zip _______

City __________________State _____ Zip ______

Phone _______________

Fax _______________

Phone _______________

Fax ______________

q Complete Record

q Partial Record ____________________________

q Partial Record ___________________________

Name:___________________________________

Name:____________________________________

Address__________________________________

Address __________________________________

City __________________State _____ Zip _______

City __________________State _____ Zip ______

Phone _______________

Fax _______________

Phone _______________

Fax ______________

q Complete Record

q Partial Record _____________________________

q Partial Record ___________________________

ealth

nformation

o: ______________________________________________________

Send

Address: ___________________________________________________________________________

City: __________________________________ State: ______________________ Zip ____________________

Fax Number: ______________________________ Phone Number: __________________________________

Signature of Patient (or Patient’s Representative)______________________________ Date

_____________

Description of Authority to Act for Patient _________________________________________

Patient Authorization To Obtain Outside Medical Records[2].doc

Created 04/07

Reviewed/Revised

Patient Authorization To Obtain Outside Medical Records Form

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