Medical Records Release And Authorization For Use Or Disclosure Of Protected Health Information Form

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Medical Records Release and Authorization
For Use or Disclosure of Protected Health Information
Please complete the following information:
Patient Name: ________________________________________________________________________
Address:
________________________________________________________________________
Phone:
________________________________________________________________________
SSN:
____________________________________ Date of Birth:_____/_____/____
I authorize the custodian of records of: __________________________________________________________
to disclose/release the following information* (Enter Name of physician or practice and Phone & Fax Number)
Patient Chief Complaint For Records:_____________________________________________________
(Enter Qualifying Condition)
All records
Laboratory/pathology records X-ray/radiology records
Billing records
Abstract/Summary
Pharmacy/prescription records Office Notes – Diagnosis and Treatments Including Med List
All dates
 These records are for services provided on the following date(s): Past 6-24 Months **If no records in time period,
then for the last visit for chief complaint
My specific authorization is necessary to release information pertaining to treatment and/or diagnosis of mental health
conditions, substance abuse, and or HIV/AIDS status. I understand that I have the right to review any mental health
information before release of such information. I authorize the release of potentially sensitive information.
 Mental Health (including anxiety and depression)  Substance Abuse
 HIV/Aids
Reason for Request:  Consultation
Transfer Of Care
Please send the records listed above to
Dustin Sulak, D.O.
and/or
Name:
___________________________
170 US Route 1, Suite 200
Address:
___________________________
Falmouth, ME 04105
___________________________
Phone 207-482-0188
Phone
___________________________
Fax 1- (888) 642-8601
Fax:
___________________________
This authorization shall expire 12 months from the date hereof unless an earlier date or event is stated here:____________
I understand that after the custodian of records discloses my health information, it may no longer be protected by federal
privacy laws. I further understand that this authorization is voluntary and that I may refuse to sign this authorization. My
refusal to sign will not affect my ability to obtain treatment; receive payment; or eligibility for benefits unless allowed by
law. By signing below I represent and warrant that I have authority to sign this document and authorize the use or
disclosure of protected health information and that there are no claims or orders pending or in effect that would prohibit,
limit, or otherwise restrict my ability to authorize the use or disclosure of this protected health information. When
required, I authorize Integr8 Health, LLC providers to discuss my case with the above provider. A copy of this
authorization is available on request.
________________________________________________
_____________________________________
Signature of patient (or patient’s personal representative)
Date
________________________________________________
_____________________________________
Printed name of patient representative
Representative’s authority to Sign
(parent, guardian, power of attorney for
healthcare, executor)
You have the right to revoke this authorization, except to the extent the custodian of records has relied on it, by sending your written
 
request to the custodian of records listed above.

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