Authorization Of Release Of Medical Records printable pdf download

AUTHORIZATION OF RELEASE OF MEDICAL RECORDS:

⃝ AGH (Atlantic General Hospital)

⃝ AGHS (Atlantic General Health System)

Please select location(s):

⃝ AHC (Atlantic Health Center)

⃝ OTHER (Specify) ____________________

PATIENT’S NAME: ______________________________________________________________________________________ DATE OF BIRTH: ___________/___________/___________

SOCIAL SECURITY #: (optional): _________________________________________ CONTACT NUMBER: _______________________________________________________________

ADDRESS: ________________________________________________________________________________________________________________________________________________

CITY: __________________________________________________________________________________STATE: ________________________________ZIP: ______________________

For this authorization my “Health Information” is: (charges may apply)

______ Complete Record (ALL)

______ Abstract Record (Discharge, Summary, History & Physical,

______

Include information from other providers/facilities

Operative Notes and Test Results)

______ Admission History & Physical

______ Pathology Report

______ Discharge Summary

______ Other: ___________________________________________

______ Outpatient Record

______ Emergency Room Record

**Please initial below if release is to include:

______ Diagnostic Test/Results Reports (lab, ex-rays and other test

_____

Drug & Alcohol Records

results)

_____

Mental Health Records

______ Digital Images (CD)

_____

Other: _____________________

______ Operative Report

**Date of Service Requested:

___________/___________/___________

I authorize __________________________________________________ to disclose/release my Health Information by:

(select one option):

⃝ Mail

⃝ Email

⃝ Pick up

PERSON OR ENTITY: _________________________________________________________________________________________

ADDRESS: ___________________________________________________________________________________________________

Medical Records

CITY: ______________________________________________STATE: ______________________ZIP: ________________________

going to:

PHONE: ________________________________________________ FAX: ________________________________________________

EMAIL: ______________________________________________________________________________________________________

For the purpose(s) of: _____________________________________________________________________________________________.

there may be a charge for copying and handling of my request

I understand

. I understand that all fees will be in compliance with

applicable Maryland State guidelines. By signing this authorization, I agree to pay these fees at the time this request is made. This

authorization is valid for one year from the date signed, unless I revoke this authorization. Atlantic General Hospital/Health System may

contact me to extend this authorization, but I do not have to do so. Atlantic General Hospital will ask me for photo identification upon

my request for my medical records. Atlantic General Hospital/Health System’s medical staff and associates are pledged to maintain strict

patient confidentiality in keeping with high ethical standards and in accordance with state and federal law. Atlantic General Hospital/Health

System has procedure in place to support this policy. These procedures make it very unlikely that my health information will be improperly

re-disclosed. However, if this happens, my health information may no longer be covered by these privacy protections. I am not required to

sign this authorization. Atlantic General Hospital/Health System does not condition treatment, payment, benefit eligibility or enrollment

activities on the signing of this form. I may request a copy of this authorization upon signature. I may revoke this authorization at any time

in writing by using the guidelines on the back of this form.

►

PATIENT SIGN HERE:

PATIENT SIGNATURE:

_______________________________________

______________DATE:

I __________________________________________________ represent that I am the healthcare Agent/Guardian/Power of Attorney/Parent of the

patient named above. (For Healthcare Agents, Guardians or Power of Attorney, attach verifying documentation.)

►

PERSONAL REPRESENTATIVE SIGN HERE:

Personal Representatives’ Signature:

DATE:

ADDRESS: ______________________________________________________________________ PHONE: ______________________________

CITY: __________________________________________________________________________STATE: ____________ZIP: ________________

Rev. 4/17/2014

PLEASE SEE THE OTHER SIDE

Authorization Of Release Of Medical Records

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