Highmark Patient Request For Medical Records Transfer Form
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3PATIENT REQUEST FOR MEDICAL RECORDS TRANSFER
AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION
PATIENT INFORMATION
PATIENT NAME
DATE OF BIRTH
/
/
ADDRESS STREET
CITY
STATE
ZIP CODE
I have been a patient of your office/facility (or am the patient’s authorized representative) and I understand that
the practice/facility provider has legally protected health information about me (or the person I represent) that I
wish to transfer.
PROVIDER THAT HAS YOUR RECORDS
I,
hereby authorize the provider to release my records:
PROVIDER NAME
ADDRESS STREET
CITY
STATE
ZIP CODE
PHONE
FAX
PROVIDER YOU WANT TO RECEIVE YOUR RECORDS
PROVIDER NAME
ADDRESS STREET
CITY
STATE
ZIP CODE
PHONE
FAX
Medical records to be release: (please check all that apply)
q Entire medical record
q Lab Results
q Operative Reports
q Emergency Department
q Radiology (x-ray, CT, MRI, etc.)
q Outpatient/Clinic (specify)
q Other (specify):
For treatment dates from
to
.
By signing below, I acknowledge that: I may revoke this authorization in writing, but it will not affect
disclosures/transfers already in progress made with this authorization
I may refuse to sign this authorization, and my treatment may not be conditioned on my signing of this form,
unless the purpose of my treatment is disclosure to a third party (for example, a drug test for employment)
I can receive a copy of this authorization upon request
A photocopy or scanned image of this authorization may be used in lieu of the original
I understand that recipients may not be subject to federal law and disclose information which I have
authorized them to receive
Signature:
Date:
If signed by a personal representative of patient, print name and relationship to patient:
Name:
Relationship:
Please attach a copy of documentation of personal representation, e.g., Power of Attorney, Legal Guardianship.
Highmark Blue Shield is an independent licensee of the Blue Cross and Blue Shield Association
MM-166 (5-17)
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