Healthcare MCS Release Form

HEALTHCARE MCS RELEASE FORM

Patient Information

Patient Name:

Date of Birth: / /

Insurance Information

Authorization for Release of Medical Chart Summary (MCS)

I hereby authorize the release of my Medical Chart Summary (MCS) and related medical information as described below. This authorization is voluntary and is given to permit the disclosure of protected health information for the purpose specified. I understand that the MCS may include clinical summaries, problem lists, medication lists, laboratory results, diagnostic imaging summaries, visit notes, and selected correspondence.

Specific Information to be Released

Check all items to be included in the MCS release:

Office visit notes and progress summaries

Current and historical medication list

Laboratory results and interpretations

Diagnostic imaging reports and summaries

Active problem list and diagnoses

Special categories (must be checked to authorize release)

Mental health treatment records

HIV-related information and test results

Substance use disorder treatment records

Purpose and Method of Disclosure

Method of release (select one or more):

Standard mail

Fax to number:

Secure electronic transmission to:

Patient or authorized representative pickup (ID required)

Fees, Expiration, and Revocation

I understand the provider may charge a reasonable fee for copying, delivery, or preparation of the MCS in accordance with applicable law. Payment of fees is due prior to release unless other arrangements are made in writing.

Revocation: This authorization may be revoked at any time by delivering a written notice of revocation to the releasing facility. Revocation will not affect disclosures already made in reliance on this authorization prior to receipt of the revocation. Revocation does not apply to actions already taken in reliance on this authorization or to uses and disclosures made pursuant to law.

Redisclosure and Legal Notice

I understand that information disclosed pursuant to this authorization may be subject to redisclosure by the recipient and, if so, may no longer be protected by federal privacy regulations. The provider is not responsible for redisclosure by the recipient. This authorization is not required for treatment, payment, or enrollment/eligibility for benefits.

Refusal to Sign

Refusal to sign this form will not affect the individual's ability to obtain treatment, payment, enrollment in a health plan, or eligibility for benefits, except to the extent that the information requested is necessary for certain administrative processes and the recipient has a right to the information.

Medical History Summary (Optional)

Certification and Signature

By signing below I certify that I am the patient or the patient's personal representative and that I have the authority to execute this authorization. I understand the meaning and effect of this authorization and request release of the information as indicated above.

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