Release Of Medical Records-Sending Records Form printable pdf download

INTERNAL MEDICINE at the CROSSINGS

Release of Medical Records – Sending Records

Patient Information:

Name: ____________________________________________________ Date of Birth: ____________________

Mailing Address: ___________________________________________________________________________

City: ___________________________________ State: ____________________ ZIP: ____________________

Last 4 digits of S.S. #: __________________ Phone Number(s): _____________________________________

Releasing Information:

I authorize Internal Medicine at the Crossings located at 3633 Crossings Drive Prescott, AZ 86305 to release the

medical records selected below.

Please select the records to be released:

____ All medical records (from the past 2 years)

____ All medical records

____ PLEASE EXCLUDE ANY RECORDS including HIV and communicable diseases, mental diseases, as

well as drug and / or alcohol related conditions.

____ Specify: ______________________________________________________________________________

Receiving Information:

I authorize the above selected records to be released to _____________________________________________

(Facility/Physician or Individual receiving records)

located at _________________________________________________________________________________,

(Address of Facility/Physician or individual receiving records)

Purpose for Release:

___ Specialist Care

___ Transferring Care

___ Personal Copy

Other: ___________________________

I understand that I may revoke this authorization at any time, except to the extent that action based on this authorization has already

been taken in reliance thereon. This content will expire automatically one year from the date of execution. Records released or

received under this authorization shall not be considered part of the records of the receiving facility. Any further disclosure of medical

record information by the recipient(s) is not authorized without the specific written consent of the person to whom it pertains.

______________________________________________

_________________________

Patient’s Signature

Date

______________________________________________

_________________________

Power of Attorney / Parent or Guardian’s Signature

Date

3633 Crossings Drive ~ Prescott, Arizona 86305

Telephone (928) 778-0330 ~ Fax (928) 778-1146

Release Of Medical Records-Sending Records Form