Authorization Form For Release Of Medical Records
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1Wardell Orthopaedics, P.C.
5818 D Harbour View Blvd., Suite 150
Suffolk, Virginia 23435
(757) 215-1400 Main Office Number
(757) 215-1410 Fax Number
Arthur W. Wardell, M.D.
Michael T. Ratanataya, PA-C
Karl F. Bowman Jr., M.D.
Diana B. Tollaksen, PA-C
Amanda L. Weller, M.D.
Authorization for Release of Medical Records
Please note that the law allows the physician two weeks to comply with your request. It also permits the office to charge a reasonable
fee for preparing records and photocopying.
PATIENT’S NAME:________________________________________________________ CHART #___________________
PATIENT’S ADDRESS: ________________________________________________________________________________
SSN: _______________________DOB: ________________HOME#___________________CELL# ___________________
I request that my medical records be released to:
q
Wardell Orthopaedics, P.C.
q
Self
Physician:__________________________ Fax#:________________________
q
Mail records to: __________________________________________________
q
q
Other, Please Specify: ___________________________________________________
______________________________________________________________
I request the following medical information be released:
Entire Chart
q
Physical Therapy Notes
q
Office Notes
q
Appointment information - verify, cancel and schedule for patient
q
Other, Please Specify:_______________________________________________
q
I understand that I have a right to revoke this authorization at any time. Please see our Privacy Official for instructions as to how to
revoke this authorization. I understand that the revocation will not apply to my insurance company when the law provides my insurer
with the right to contest a claim under my policy. Unless otherwise revoked, this authorization will expire on the following date:
. If I fail to specify an expiration date, this authorization will expire in one (1) year.
I understand that authorizing the disclosure of this health information is voluntary. I can refuse to sign this authorization. I need not
sign this form in order to ensure treatment.
I understand that any disclosure of information carries with it the potential for an unauthorized re-disclosure and the information may
not be protected by federal confidentiality rules. If I have questions about disclosure of my health information, I can contact Wardell
Orthopaedics, P.C. Privacy Official at (757) 215-1400.
PATIENT SIGNATURE:
DATE: ________________
_________________________________________________
If Signed by Legal Representative, Relationship to Patient
billing forms/front desk/medical release main office updated 01-05-15/el
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