Medical Release Of Records -Clayton State University printable pdf download

Medical Release Of Records -Clayton State University

University Health Services

2000 Clayton State Blvd.

Student Center Bldg, Rm 211

Morrow, GA 30260

P: (678) 466 – 4940

F: (678) 466 – 4944

Authorization to Release Medical Records

Patient Name: ____________________________________

Date of Birth: ______/______/_________

Laker ID: ___________________________

Phone: (______)________-____________

Driver License #: _________________________

State of Issue: ________

I, _________________________________ authorize _____________________________ to release the following records

(Clinic or Office Name)

included in my medical chart.

Office Phone: (______)________-____________

Office Fax: (______)________-____________

Please check all that apply.

____Physician Notes

____Immunization Records

____Lab Results

____Complete Records

____X-Ray Reports

____HIV Testing Information

____Pap Exam

____Diagnostic Test

I hereby release CSU University Health Services from any liability which may result from this disclosure of confidential

information, or which may arise as a result of the use of the information contained in the information released. I

understand that I may revoke this authorization by providing written notice by intention. Unless withdrawn, this

consent will expire 90 days from the date signed. Date Expired: ______/______/_________

____This information may include Psychiatric and HIV/AIDS information.

____I authorize that this information may be faxed to the requesting Health Care Provider.

Patient’s Signature: ______________________________________________ Date: _____/________/________

Patient’s Representative: __________________________________________ Date: _____/________/________

(Relationship to Patient)

Authority to sign on behalf of the patient is authorized by __________________________________.

Witness by: _________________________________________

(Picture ID and the patient’s signature were used to verify identity.)

Please note:

Records requested for continued care will be mailed directly to the Doctor/Health Care Provider.

Medical Release Of Records -Clayton State University