Medical Records Release printable pdf download

David L. Kreger, M.D., F.A.C.P., F.A.C.G.

Alan J. Gamsey, M.D., F.A.C.P., F.A.C.G.

Steven M. Dandalides, M.D., F.A.C.P, F.A.C.G

Felix P. Tiongco, M.D., F.A.C.P.

Pramod Malik, M.D., CPI

Walid F. Makdisi, M.D.

Brian M. Sullivan, M.D.

MEDICAL RECORDS RELEASE

Patient Name: _____________________________________________

Date of Birth: ___________________ Account #: _______________

Patient Social Security Number: ________________________________

X At the request of the above named individual, please Release Records to:

Gastroenterology Associates of Tidewater,

5701 Cleveland St., Suite 100,

Virginia Beach, VA 23462

(757) 547-0798

(757)547-0145

Phone Number

Fax number

Request records from:

________________________________________________________________

Name

________________________________________________________________

Address, City, State & Zip

(_______)_____________________

(_____)_________________

Phone Number

Fax number

Information Requested for medical treatment:

All medical records: without exception, including progress notes, lab reports, consultations, hospital

notes, procedure/operative reports.

Partial medical records: Check which records are being requested

progress notes

lab reports

Consultations

Hospital notes

procedure/operative report

Other(specify) __________________________________________

I hereby authorize the use or disclosure of my protected health information (PHI) as described above. I

understand that this authorization is voluntary. I understand that ability to obtain treatment will not be affected if I do no sign this

form, unless that treatment is for a fitness-for-duty evaluation or a research-related treatment. I understand that if they organization

authorized to receive the information is not required to comply with the federal privacy protection regulations, then such information

may be re-disclosed and will no longer be protected. I understand that I have the right to revoke this authorization by sending written

notification to Tidewater Gastroenterology, PLLC, 112 Gainsborough Square, Suite 200; Chesapeake, VA 23320.

Any revocation will not affect disclosures made prior to Tidewater Gastroenterology’s receipt or knowledge of the revocation. Unless I

revoke this authorization prior to such a time, this authorization shall expire:__________________ (90 days if left blank) from the date

of my signature. I understand that I have the right to inspect and receive a copy of the information described on this form.

_______________________________________________ ___________________

Signature of patient or patient’s authorized representative

Date

_____________________________________________ ___________________

Printed name of patient’s representative (if applicable) Relationship to patient

Norfolk Office

Virginia Beach Office

Chesapeake Office

160 Kingsley Lane, Suite 200

5701 Cleveland Street, Suite 100

112 Gainsborough Square, Suite 200

Norfolk, Virginia 23505

Virginia Beach, VA 23462

Chesapeake, Virginia 23320

(757) 889-6800

(757) 547-0798

Fax (757) 547-0145

“A Division of Tidewater Gastroenterology, PLLC”

Medical Records Release

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