Medical Records Release Request Form


Authorization for Use or Disclosure of Protected Health Information
Please complete the following information:
Patient Name:
Address: _______________________________________________________________
Phone: _______________________________________________________________
SSN: ____________________________________Date of Birth:_____/_____/_____
I authorize the custodian of records of:
or other
person/entity (specifically
describe) to disclose/release the following information* (check all applicable):
o All records
o Laboratory/pathology records
o X-ray/radiology records
o Billing records
o Abstract/Summary
o Pharmacy/prescription records
o Other (describe specifically)
*Note: If these records contain any information from previous providers or information about HIV/AIDS status,
cancer diagnosis,
drug/alcohol abuse, or sexually transmitted disease, you are hereby authorizing disclosure of this information.
These records are for services provided on the following date(s):
Please send the records listed above to (use additional sheets if necessary):
Name: _________________________
Name: ___________________________
Address: _________________________
Address: __________________________
Phone: _________________________
Phone ___________________________
Fax: _________________________
Fax: ___________________________
This authorization may not be valid for greater than one year from the date this form is
signed. I understand that after the custodian of records discloses my health information, it
may no longer be protected by federal privacy laws. By signing below I represent and
warrant that I have authority to sign this document and authorize the use or disclosure of
protected health information and that there are no claims or orders pending or in effect that
would prohibit, limit,or otherwise restrict my ability to authorize the use or disclosure of this
protected health information.
Signature of patient (or patient’s
personal representative)
____________________________________ __________________________________
Printed name of patient representative Representative’s authority to sign for patient,
parent,guardian, power of attorney for healthcare, executor)
You have the right to revoke this authorization, except to the extent the custodian of records has
relied on it, by sending your written request to Meher S. Khan MD 146 Montgomery Avenue Bala
Cynwyd PA 19004
Meher S. Khan MD
146 Montgomery Avenue
Bala Cynwyd PA 19004
(610)668-0836 Fax (610) 668-7922


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Parent category: Legal