Medical Records Release Form - Premier Physicians
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1PREMIER PHYSICIANS
P.O. Box 5291
Midland, Texas 79704
432 686-6600
FAX 432 682-2284
MEDICAL RECORD REQUEST FORM
In accordance with the Health Insurance Portability and Accountability Act of 1996 you are giving permission to release Protected Health
Information as defined herein. Understanding that this authorization may be re-disclosed to additional parties and will no longer be protected
by HIPAA. Further understanding that this may be revoked at any time by contacting the below Medical Records Officer, and that such a
revocation does not apply to the extent that persons authorized to use or disclose the health information have already acted in reliance on
this authorization.
Name:
Date:
Date of Birth:
SSN:
Phone:
I hereby request and authorize: (Doctor’s Name)
(Clinic Name)
To release my personal medical information to:
(Doctor’s or Person’s Name)
(Address, City
State. ZIP)
Purpose of the Release:
Treatment Dates to be Released:
As required by HIPAA any release of Protected Health Information may only be strictly “minimum necessary”
except when defined as to date and substance. (Complete Chart is Unacceptable when not defined by date etc.)
Information Requested in the above time period: (please check requested areas)
Physician Office Notes
___Pathology Reports
___Psychiatric Notes (
see restrictions for release)
Lab Reports
___Surgical Reports
Billing/Collections
X-Ray Reports
___Consult Notes
___Other:
Other Diagnostic Studies
___Physical Therapy Notes
HIV / AIDS: I consent to the release of any positive or negative test result for AIDS or HIV infection,
antibodies to AIDS or infection with any other causative agent of AIDS with the rest of my medical
records. Initial:
Date:
In requesting the medical records I understand there maybe fees for preparing and furnishing the information, per TEXAS State Board of
Medical Examiners regulations as follows: $25.00 for pages 1-20 and $0.50 per page for each page there after. This will include postage to
send if necessary. The request will be completed within 15 business days following full payment of required amount for each record.
I understand this information release is for the specific purpose above and may not be provided in whole or in part to any other
agency, organization or person. I understand this correspondence and records from other health care providers will not be released. I may
revoke this authorization at any time and this authorization expires 180 days from the date of signature unless otherwise specified.
Patient Signature or Legal Representative
Date
Relationship to Patient
Witness
Fee Paid
_______________________________________
Records Sent
Date
Authorization withdrawn—Signature & Date
Initial Personnel
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