General Request For Release Of Medical Uofl Physicians
ADVERTISEMENT
1GENERAL REQUEST FOR RELEASE OF MEDICAL RECORDS
To be used for release of information to the patient, their legal representative,
or to a provider of their choice; or to request records from another provider.
In order to release your/the patient’s records, you must sign a request for release. This form must be
complete with the patient’s name, the last 4 digits of the patient’s social security number, and the patient’s
date of birth. It is your responsibility to read this form in full and to ask any questions before the record is
released. No phone call requests will be honored.
Designate Who You Want to Release Your Records
University of Louisville Physicians, Inc. (UofL Physicians) Release Your Records
The following information explains our policy for releasing protected health information:
Medical records will be released only to the patient or the patient’s authorized representative. Law
office/attorney medical records requests must have valid authorization with request.
Please be prepared to show ID when picking up records in person. This is for the protection of your personal
health information.
Patient’s legal representatives must provide appropriate documentation to demonstrate their legal status.
HIV, STD, substance abuse, and psychiatric records are not released without specific separate
authorization.
Please allow up to 30 days for records stored off site; however, UofL Physicians may take up to 60 days to
process the request, if necessary.
First copy provided free of charge.
Release Records to (provide information below):
Patient/Legal Representative
Provider Office
Name ______________________________________________ Phone __________________________
Address _____________________________________________________________________________
Street
City
State
Zip
Another Provider Release Your Records to UofL Physicians
Provider Name _______________________________________ Phone __________________________
Provider Address ______________________________________________________________________
Street
City
State
Zip
Patient Information, Signature, and Records Being Released
______________________________________ __________________ _________________
Patient’s Name (Please Print)
Date of Birth
Last 4 Digits of SSN
______________________________________ _______________________________ ____________
Patient/Parent/Legal Guardian Signature
Witness Signature
Date
If Parent/Legal Guardian, Print Name ________________________________________
Records Being Released :
Date Range
From _______________
To _______________
Entire Chart
Labs
Office Notes
Other (Specify Below)
__________________________________________________________________
Do Not Write Below This Line – For Office Use Only
UofL Physicians Practice Site
_____________________________________________________
(optional)
Phone _________________________ Fax _______________________
HIP-10F
Revised February 19, 2014
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal