Healthcare Duplicate Form

HEALTHCARE DUPLICATE FORM

Patient Information

Date of Birth:    Gender:

Phone:    Email:

Emergency Contact

Relationship:    Phone:

Insurance Information

Medical History (Summary)

Duplicate Request Details

Duplicate Requested For (check all that apply):

Complete Medical Record Laboratory Reports Imaging Reports Billing Statement Other

Date Range of Records Requested: From to

Purpose of Request:

Personal Continuity of Care Insurance Legal Other

Preferred Format:

Paper Copies Electronic PDF CD / Media Other

Delivery & Fees

Delivery Method:

Mail to Patient Address on File Pickup In Person Email to Patient Other

I acknowledge that fees for duplication and postage may apply and are to be paid prior to release. Processing may require up to 30 days unless otherwise required by law. The provider may withhold information protected by law and will provide a written statement if any portion is withheld.

Authorization and Release

I hereby authorize the release of the duplicate records described above to the patient named on this form or to the designated recipient. I understand that this authorization permits disclosure of medical information necessary to fulfill this request and does not authorize further redisclosure beyond the purpose stated. I may revoke this authorization at any time by submitting a written revocation, except to the extent that action has already been taken in reliance on this authorization.

Authorization Expiration Date:

Identification Presented (type and number):

Representative Authorization (if signing on behalf of patient): Relationship to Patient:

By signing below I certify that I am the patient or an individual authorized to act on behalf of the patient and that the information provided on this form is true and accurate. I understand that falsifying information may subject me to penalties under law.

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