Medical Records Release Form printable pdf download

Medical Records Release Form

I hereby authorize the use or disclosure of health information from the medical record of:

Patient Name ________________________________________ Date of Birth _____/_____/_____

Social Security # _______________________________

I authorize TEXAS ORTHOPEDICS, SPORTS AND REHABILITATION ASSOCIATES to release confidential health

information about me, by releasing a copy of my medical records, a summary or narrative of my protected health

information, or verbally to the individual or organization listed below.

Specific Description of the Information to be released:

 Progress Notes

 Radiology films (performed at Texas Orthopedics)

 Other ________________________

 Diagnostic study reports (labs, radiology, etc.)

 Outside records (hospital, therapy, other doctors)

_____________________________

I understand that the information in my health record may include information relating to sexually transmitted

disease, acquired immunodeficiency syndromes (AIDS), or human immunodeficiency virus (HIV). It may also

include information about behavioral or mental health services, and treatment for alcohol and drug abuse.

 Yes, I consent to the release of this information.

 No, I do not consent to the release of this information.

This information may be disclosed to and used by the following individual or organization:

Name: ______________________________________________________________________

Address: _____________________________________________________________________

Phone: ________________________ Fax: _________________________

The reasons or purposes for this release of information are as follows:

_____________________________________________________________________________

I understand that the information released is for the specific purpose stated above. Any other use of this

information without the written consent of the patient is prohibited. However, I understand that any disclosure of

information carries with it the potential for an unauthorized re-disclosure and the information may not be protected

by federal confidentiality rules.

I understand that I may revoke this authorization at any time by notifying Texas Orthopedics in writing. I

understand that the revocation will not apply to information already released in response to this authorization. I

understand that the revocation will not apply to my insurance company when the law provides my insurer with the

right to contest a claim under my policy.

Unless otherwise revoked, this authorization will expire on the following date, event or condition:

_______________________________. If I fail to specify an expiration date, event or condition, this

authorization will expire in one year.

_________________________________________

__________________________

Signature of Patient or Legal Representative

Date

_________________________________________

Relationship to Patient (If Legal Representative)

Office Use Only:

Chart#: _________________

Request received: ________ Request completed:____________ Initials: ____________

Charges $_______________ Payment received: ________________

113_600

Updated 7/16/09

Medical Records Release Form

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