Authorization To Release Medical Records/information

ADVERTISEMENT

PEDIATRIC ASSOCIATES
1717 HIGH STREET SUITE 3A
HOPKINSVILLE KY 42240
PHONE (270) 885-8445 ~~ FAX (270) 886-9106
Authorization to Release Medical Records/Information
IMPORTANT:
IN FULL
PLEASE FILL OUT EVERY LINE
WITHIN THE SHADED AREA
Fax #: _____________
:______________________________________Phone #: ___________
FULL NAME of Physician providing records
Street: _______________________________________________________________________________________
City: _________________________________________________State: ___________ ZIP:__________________
Patient’s name:_____________________________________________________DOB:______________________
Your Current Phone Number: __________________________________________________________________
:________________________________________Phone #: ___________
Person/facility (full name) to receive records
Address:_______________________________________________________________________________
City, State, Zip:_________________________________________________________________________
REASON FOR TRANSFER/COPYING OF RECORDS_____________________________________________
_____________________________________________________________________________________________________________________
READ CAREFULLY BEFORE SIGNING:
If you are transferring a patient’s records to another local physician please let it be called to your
attention that this patient may not be able to be seen in our office effective the date of transfer.
ALL MILITARY PERSONNEL:
If you are a Military person and are TEMPORARILY being transferred to another location, please
write (MILITARY MOVE) on this form for the reason for transfer of records.
Please check the specific protected health information that is to be disclosed to Pediatric Associates
Initials
1. Only records generated by this facility (not including records received from other sources)
______
2. Only some portion of records maintained at facility (dates of treatment, etc, specify below)
______
3. All medical records at this facility
________
IF YOU DO NOT WANT CERTAIN PORTIONS OF YOUR MEDICAL RECORDS RELEASED, PLEASE READ
THIS SECTION CAREFULLY AND INITIAL THE BOXES FOR INFORMATION YOU DO NOT WANT
RELEASED. OTHERWISE, YOUR RECORDS WILL BE RELEASED AS SPECIFIED ABOVE.
I authorize the heath care provider to release the information specified to the organization, agency or individual
named on this request with the EXCEPTION of:
INITIALS
INITIALS
________ Substance abuse, if any
________AIDS/HIV, if any
________Psychological or psychiatric conditions, if any
Other (Please Specify)___________________________________________________________________________
Expiration or revocation of authorization – I understand that I may revoke this authorization at any time and that unless an earlier
date is specified it will automatically expire 12 months after date affixed above.
Use of copies – A copy of this authorization may be utilized with the same effectiveness as an original.
Patient name
Person authorized to sign for patient:
___________________________________________
______________________________________________
Please Print
Please Print
___________________________________________
______________________________________________
Relationship to patient (Please print)
Signature
Date:______________________________________
Date:__________________________________________

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Business
Go