Authorization For Release Of Medical Information Form (Page 2 of 2) in pdf

Authorization For Release Of Medical Information Form Page 2

GUIDELINES FOR COMPLETING

“AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION” FORM

Name of Patient:

Legal name of patient.

Medical Records No: Number assigned to patient (if unknown, leave blank)

Date of Request:

The date information is requested from Blessing or the date that Blessing is requesting

information.

Date Needed:

Only to be used as a guide for Blessing Hospital on when a requesting party needs the

requested information.

Date of Birth:

Patient’s date of birth.

FROM:

Please select which Blessing entity records are being requested from.

TO:

Write name of where records are to be sent. If patient is taking records to someone else, write

patient’s name.

Date of Service:

Date of records needed, this can be a date range (i.e. “99 to present”, or specific lab report on

06/01/01).

Type of Record

Check the box that applies (i.e. “Mental Health Records”).

Requested:

Purpose:

Check box that applies. “Sharing with other healthcare providers” could be to give or receive

information.

Expiration:

Any date can be written here, if left blank, 6 months may apply.

Authorization For Release Of Medical Information Form Page 2