Healthcare Information Request Form

HEALTHCARE INFORMATION REQUEST FORM

Patient Information

Patient Name:

Date of Birth:    Gender:

Requesting Party / Recipient of Records

Phone:    Fax:

Records to Be Released

Select records to be released (check all that apply):

Entire Medical Record    Operative/Procedure Reports    Laboratory Reports    Imaging Reports (e.g., X-ray, MRI)

Billing / Account Information    Consultation / Progress Notes    Other:

Date range for records to be released from to

Sensitive Information

Certain categories of health information may require specific authorization. By checking any of the boxes below, you specifically authorize release of these sensitive records.

Mental health / psychotherapy notes    Substance use treatment records

HIV / AIDS related information    Genetic testing results

Purpose of Disclosure

Continuity of care / treatment    Insurance / claims    Personal use

Legal matter    Other:

Method of Disclosure

How should records be delivered? (select all applicable)

Mail (paper)    Fax    Secure Email    Pick up in person    Electronic portal / CD

Fees

I understand that reasonable fees for copying, labor and postage may be charged in accordance with applicable law.   Waive fees where permitted by law

Authorization and Acknowledgment

I authorize the release of the medical information specified above to the requesting party named in this form. I acknowledge that:

1. This authorization is voluntary and I may refuse to sign. My refusal will not affect my treatment, payment, enrollment, or eligibility for benefits unless allowed by law.
2. I understand that information used or disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and may no longer be protected by federal privacy regulations.
3. I may revoke this authorization in writing at any time except to the extent that action has been taken in reliance on the authorization. To revoke, I must notify the health information custodian in writing.
4. If I am authorizing release of psychotherapy notes, HIV-related information, genetic testing, or substance use disorder treatment records, I understand that specific consent is required and that such records will only be disclosed if I have specifically indicated approval under Sensitive Information above.

Certification

By signing below I certify that I am the patient or am authorized to act on behalf of the patient. I further certify that the information provided on this form is true and correct to the best of my knowledge.

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