Grove Medical Associates, P.c. - Auburn, Maine printable pdf download

GROVE MEDICAL ASSOCIATES, P.C.

250 Hampton Street, Auburn, MA 01501 T: 508-753-2060 F: 508-752-4244

CONSENT FOR RELEASE OF MEDICAL INFORMATION

Please print all information

Name of Patient: ________________________________________________ DOB: ______________________

Patient’s Street Address: _____________________________________________________________________

______________________________________________________ Telephone: _________________________

Reason for request: ⁭ getting second opinion only

⁭ living elsewhere during part of year

⁭ leaving group

due to move ⁭ leaving group due to dissatisfaction ⁭ switching PCP

⁭ records for specialist appointment

⁭ other: _______________________

As the patient or the patient’s legal representative, I authorize:

Name of physician:__________________________________________________________________________

Address of physician: ________________________________________________________________________

To disclose to:

Name of recipient:___________________________________________________________________________

Address of recipient:_________________________________________________________________________

If these records are to be picked up at our offices, I authorize them to be released to:

Name of recipient: __________________________________________________________________________

Address of recipient: ________________________________________________________________________

Relationship to patient: ______________________________________________________________________

MEDICAL RECORDS (Please check one.)

I specifically _____________________ to the disclosure and release of sensitive medical information concerning my

(consent or refuse)

treatment of mental illness, Human Immunodeficiency Virus, drug addiction, abuse, or dependency, or venereal disease, if

any.

⁭ Only those specific records as I describe:

__________________________________________________________________________________________________

__________________________________________________________________________________________

I may withdraw my consent by giving written consent to the above party, at any time prior to the disclosure or release of

the information. In the absence of the withdrawal of permission, this consent will expire one year after it is signed. A

photographic copy of this authorization shall be as valid as the original.

I may refuse to sign this authorization. If so the refusal will not affect my ability to obtain treatment or payment or

eligibility for benefits.

If my information is used or disclosed pursuant to this Authorization, it may be subject to re-disclosure by the recipient

and, as a result, it may no longer be protected by the Privacy Rule.

Massachusetts law requires medical records to be copied within thirty days from receipt of the request and allows for a

reasonable processing fee. I agree to pay this fee.

_____________________________________

______________________________

Authorized Signature

Date

_____________________________________

__________________________________________

Print Name

Relationship if not patient or custodial parent

(Must prove guardianship or other legal authorization)

Grove Medical Associates, P.c. - Auburn, Maine

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