Standard Medical Record Release Form

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Patient’s Name: __________________________________________________________________ History #: _________________
Patient’s Date of Birth: ________________________________________ Date(s) of Service: _____________________________
Patient’s phone number: (
) __________________________________ (
) ________________________________
DAYTIME
EVENING
I authorize: ______________________________________________________________________________________________
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:
❑ Emergency Record
❑ X-ray Report
❑ Billing Information
❑ Face Sheet
❑ Progress Notes
❑ Substance Abuse Records
❑ Discharge Summary
❑ Lab / EKG
❑ Plan of Care (HH)
❑ Psychiatric Admit Note
❑ Operative Report
❑ Complete Health Record
❑ Psychiatric Evaluation
❑ Physicians Orders
❑ Medical Abstract
❑ Consultation
❑ Other _______________________
❑ X-ray Films/CD
Purpose:
❑ Medical Follow-Up
❑ Individual use
❑ Insurance
❑ Attorney
❑ Disability
❑ Other ________________________
❑ Yes
❑ No
❑ N/A
Patient advised of charges:
❑ I prefer to pick up records
❑ I wish to review records (by appointment only)
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 I am under no obligation to sign this form. Inova Health System may, however, condition the provision of
research-related treatment on my signature of this authorization for the use or disclosure of protected health information
for such research, in accordance with the Health Insurance Portability and Accountability Act (HIPAA), Standards for
Privacy of Individually Identifiable Health Information (Privacy Standards), 45 CFR Parts 160 and 164, §164.508(b)(4). Inova
Health System may also condition the provision of health care that is solely for the purpose of creating protected health
information for disclosure to a third party on my signature of 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
PATIENT IDENTIFICATION
INOVA HEALTH SYSTEM
INOVA INITIATED AUTHORIZATION TO
RELEASE / DISCLOSE PROTECTED
HEALTH INFORMATION
CAT #84515 / R032403 • PKGS OF 100

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