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Medical Records Release Authorization Form
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Medical Records Release Authorization
Patient's Name:
*
D.O.B.:
*
Parent/Guardian:
*
Relationship:
*
Phone:
*
Parent Permission for Records Release
I hereby give
Name of Doctor or Facility:
*
permission to release all records as indicated below, to
Name of Doctor, Facility or Self:
*
Medical Records Release To Whom
Release Records to the following Person(s) or Organizations:
Name*:
Address*:
Phone / Fax*:
Email:
Purpose of Records Release
These records will be released for the purpose of:
Patient Care
School
Personal Use
Specialist
Changing Practices
Attorney/Client
Insurance
Moving
Other:
Records Released Will Include
The records to be released will include (please check only one of the following two options):
Entire Medical Record including diagnoses and treatment of behavioral and/or mental health, HIV/AIDS related health information, pregnancy records, drug/alcohol diagnosis, treatment, and/or referral information, information about sexually transmitted disease, and birth control records.
OR - Please release only the following:
Immunization Records
Growth Charts
Medication List
Lab Results
Imaging Results
Behavioral and/or mental health records
Drug/alcohol diagnosis, treatment, and/or referral information
HIV/AIDS related health information and/or records
Information about sexually transmitted disease
Pregnancy records
Birth control records
Other
Explain Other:
I understand that I have the right to inspect and copy the information I have authorized to be disclosed by this authorization. In the event I refuse to authorize the release of the above-described information, I understand that it will not be disclosed, except as provided by law. I understand that the practice may not condition treatment on whether I sign this authorization, except when the provision of healthcare is solely for the purpose of creating protected health information for disclosure to a third party. I understand that this authorization is valid for one full year unless a written letter of termination is received. I understand that I may revoke this authorization at any time by giving written notice to the physician of my desire to do so. I also understand that I will not be able to revoke this authorization in cases where the physician has already relied on it to use or disclose my health information. Written revocation must be sent to the physician’s office. Absent such revocation, the Authorization for Release of Confidential Health Information will terminate on
Date:
Parent Signature
Signature of Parent/Legal Guardian:
*
Relationship:
*
Date:
*
If this patient is 12 years old or older, the patient must also sign below to authorize the release of this information.
Patient Signature (if 12 years or older):
Date:
Security code:
Enter security code: