Fillable Marymount Hospital Medical Release Form printable pdf download

MARYMOUNT HOSPITAL

MR #

12300 McCracken Road

RECORDS SENT

Garfield Heights, OH 44125

FAX 216.587.8043

216-587-8224

AUTHORIZATION FOR RELEASE OF MEDICAL, SURGICAL OR BEHAVIORAL INFORMATION

Patient Name: _______________________________________________________________

Birth Date: __________________

Last, First, Middle Initial

Address: ___________________________________________________________________

Phone No: __________________

City, State, Zip Code: ________________________________________________________

Soc. Sec. No: ________________

Release Information To: _______________________________________________________

Phone No: __________________

Name of Person/Doctor/Hospital

Address: ___________________________________________________________________

City, State, Zip Code: ________________________________________________________

I hereby authorize Marymount Hospital to release the health information indicated below that is contained in my patient records to the

Recipient named above. I understand that the information in my health record may include information relating to sexually

transmitted disease, acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV).

CHECK ALL THAT ARE REQUESTED FOR THE SPECIFIED DATES BELOW:

Discharge Summary

Radiology/Ultrasound Results

History & Physical

EKG/ECG

Consultation

Outpatient Surgery / Endoscopy

Operative Report

Emergency Department Record

Pathology Report

Behavioral Health Record

Lab Results

Cleveland Clinic Homecare Services

Other (specify) __________________________

Dates of hospitalization/treatment: _______________________________________________________________________________

Purpose/Need for information (check one):

Continuity of Care/Follow Up

Legal

My Personal Records

Other (specify) __________________________

I understand that I have a right to revoke this authorization at any time. I understand that if I revoke this authorization, I must do so in

writing and present my written revocation to the Medical Records Department Director. I understand that the revocation will not

apply to information that has already been released in response to 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.

This authorization and consent will expire one year from the date of authorization written below.

I understand authorizing the use or disclosure of the information identified above is voluntary. I need not sign this form to ensure

healthcare treatment.

AUTHORIZING SIGNATURE: _____________________________________________________

Date: ________________

Signed by:

Patient

Legal Guardian

Executor of Estate

Other (specify) ____________________________

I understand that once the above information is disclosed, the recipient may redisclose it and the information may not be protected by

federal privacy laws or regulations.

**If other than patient’s signature, a copy of legal papers verifying authority (e.g., Healthcare Power of Attorney or Death Certificate

& Executor of Estate papers) MUST accompany the authorization when presented. Exception: Custodial parent is signing for patient

under age 18. Proof of custody may be required.

A picture ID will be required either upon filling out the authorization form or picking up the records.

Charges as laid out by OH law may be applied for obtaining copies of your medical record.

Rev. 01.12

Marymount Hospital Medical Release Form

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