Healthcare Medical File Request

HEALTHCARE MEDICAL FILE REQUEST

Patient Information

Patient Name:

Date of Birth:    Medical Record No.:

Records Custodian / Facility

Records Requested

I request that the following records be prepared and released as indicated. Select all that apply:

All medical records from the custodian's file

History & Physical    Progress Notes

Operative / Procedure Reports    Discharge Summary

Laboratory Reports    Radiology Reports / Images

Pathology    Medication / Medication Administration Records

Billing / Account Statements    Other (describe below)

Date Range for Records: From to

Delivery / Release Instructions

Release records to:

Preferred method of delivery (select all that apply):

Standard mail    Patient pickup

Fax to:  

Encrypted email to:  

Electronic portal / secure transfer

Fees and Charges

I understand that reasonable fees for copying, postage, and preparation may apply and I agree to pay applicable fees unless otherwise waived by the custodian. I authorize the custodian to charge reasonable fees for duplication and delivery of records.

I agree to pay applicable fees.

Sensitive Information — Specific Authorization

Certain records require explicit authorization for release. Check each category you authorize to be released as part of this request. Unless checked below, these records will not be released.

HIV/AIDS related records

Mental health / psychotherapy notes

Substance use disorder treatment records (including SUD treatment program records)

Purpose of Disclosure

Purpose (select one or more):

Continuation of care / treatment    Personal copy

Insurance / claim    Legal    Other:

Expiration; Right to Revoke

This authorization will expire on: . If left blank, this authorization expires 12 months from the date of signature. I may revoke this authorization in writing at any time, except to the extent that action has already been taken in reliance on it.

Redisclosure and Limitations

I understand that once my records are disclosed to the recipient named herein, federal privacy regulations may no longer protect the confidentiality of my records and the recipient may re-disclose them. This authorization does not authorize the release of records not identified above unless required for the stated purpose and permitted by law.

HIPAA Acknowledgement

I acknowledge that I understand my rights under the Health Insurance Portability and Accountability Act (HIPAA) with respect to authorizing the release of my protected health information. I understand that I am not required to sign this form and that treatment, payment, enrollment, or eligibility for benefits will not be conditioned on signing this authorization except as permitted by law.

I acknowledge the statements above.

Certification

By signing below, I certify that I am the patient or am authorized to act on behalf of the patient as the patient's personal representative. I authorize the release of the records described above. I certify that the information I have provided on this form is true and correct to the best of my knowledge.

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