Authorization For Records Release Form printable pdf download

AUTHORIZATION FOR RECORDS RELEASE

Patient’s Name: _____________________________________________

Patient’s Date of Birth: ___________

Patient’s phone number: (______) __________________________

(______) __________________________

DAYTIME

EVENING

I authorize Inova Medical Group – ALFA Neurology to release or disclose the following information to:

_____________________________________________________

_______________________________

NAME OF PERSON, PHYSICIAN OR AGENCY TO RECEIVE INFORMATION

(FAX NUMBER FOR PHYSICIAN OFFICE ONLY)

__________________________________________________________________________________________

STREET ADDRESS

CITY

STATE

ZIP CODE

Information to be Released / Disclosed:

Pathology

X-ray Report

Other ___________________

Lab / EKG

Office Notes

Hospital/Specialist Reports

Complete Health Record

Purpose:

Medical Follow-Up

Individual use

Insurance

Attorney

Disability

Other ________________________

I prefer to pick up records

I understand that if the person or agency that receives my information is not a health care provider or health plan

covered by the HIPAA privacy regulations, the information described above may be redisclosed and is no longer

protected by these regulations.

I understand written notification is necessary to cancel this authorization and can be addressed to the department

listed at the top of this form. I am aware that my cancellation will not be effective as to disclosures already made

in reference to this authorization.

I understand that this disclosure may include information regarding drug abuse, alcoholism, or alcohol abuse,

psychiatric or mental illness, Acquired Immunodeficiency Syndrome (AIDS) or infection with HIV regulated by

Federal Statute (42 CFR Part 2).

_________________________________________

_______________________________________

SIGNATURE OF PATIENT OR REPRESENTATIVE

DATE (This authorization will expire 6 months after date signed)

__________________________________________

_______________________________________

NAME OF PERSONAL REPRESENTATIVE (IF APPLICABLE)

RELATIONSHIP TO PATIENT

MEDICAL RECORDS FEES

If requesting most recent lab and office note to be sent to a physician, there is no charge. If requesting copies for

your own records, the following charges will apply (per Virginia code):

Copies of pages 1-50 ______@ $0.50/page

$____________

Copies of pages 51 + ______@ $0.25/page

$____________

You may return via Fax (703) 280-1235 or mail to: Inova Medical Group – ALFA Neurology

8505 Arlington Blvd, STE 450

Fairfax, VA 22031

You may return via Fax (703) 845-1300 or mail to: Inova Medical Group – ALFA Neurology

1500 N. Beauregard Street, STE 300

Alexandria, VA 22311

Authorization For Records Release Form

Related Articles

Related forms

Related Categories