Medical Records Release Form Authorization Of Health Or Billing Information
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1Medical Records Release Form
Authorization of Health or Billing Information
Patient Name:
Patient Address:
Date of Birth:
Phone Number:
I give permission to:
To release my information to:
(Name of Person/Facility)
(Name of Person/Facility)
(Address)
(Address)
(City/State/Zip)
(City/State/Zip)
(Phone)
(Fax)
(Phone)
(Fax)
Please Check Information to be Released:
□ Registration Information □ Specific Treatment Dates: □ Entire Medical Record
□ Insurance Information
_ ____________________ □ Immunization Record
□ Medication Records
_ ____________________ □ Other ___________________
□ Consultation Notes
□ Growth Chart □ Labs
□ Xrays □ Psychiatric Notes
Describe Reason for Release:
□ Insurance
□ Legal
□ Changing Physicians (
if choosing this option please let us know
why)
□ Other
___________________________________
Records to be Released by:
□ Mail (will be mailed to whomever information is being released to)
□ Fax (cannot fax entire medical record)
□ Pick-Up in person
□ Other (describe) ______________________________
**Fee for copying/handling entire medical record is $20.00. You will be pre-billed for the records.
As soon as the invoice is paid your records will be mailed on CD/R unless requested on paper.
Please allow 5-10 business days for records to be received.
I authorize the disclosure of medical information for the above named patient(s). I understand that
this authorization is voluntary and may be revoked in writing at any time. I understand that this
authorization may be revoked in writing, unless the medical records have already been disclosed. I
understand that this authorization includes consent for information that may include susbstance
abuse, mental health, and HIV/AIDS. I understand that this authorization is valid for 12 months
from the date signed.
__________________________________________________________________
Patient/Parent Signature
Date
____________________________________________________________________________________________
Print Name
Relationship to Patient
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Parent category: Legal