Healthcare Medical Record Request

HEALTHCARE MEDICAL RECORD REQUEST

Use this form to request release of protected health information (PHI) from a healthcare provider or facility to a designated recipient. Complete all sections, sign and date. Failure to provide complete information may delay processing. This authorization is voluntary and may be revoked as described in the Patient Authorization section below.

Patient Information

Patient Name:

Request Details

Records requested from:

From: To:

Sensitive Information — Patient Initials Required to Authorize Release

The following categories of information are treated as especially sensitive. Initial next to each category to specifically authorize release of that category. If no initial is provided, that category will not be released.

Mental health records (psychotherapy notes are not released unless specifically authorized): Initials:

Substance use treatment records (chemical dependency): Initials:

HIV/AIDS-related information: Initials:

Purpose of Disclosure

Recipient / Delivery Instructions

Patient Authorization and Acknowledgment

I authorize the release of the health information described above to the recipient identified on this form. This authorization includes all records created by the releasing provider or facility unless explicitly excluded. I understand that once my information is released, it may be subject to redisclosure by the recipient and may no longer be protected by the releasing provider's privacy policies.

I understand that I may revoke this authorization in writing at any time except to the extent that action has already been taken in reliance on this authorization. To revoke this authorization I must send a written notification to the releasing provider. Unless revoked earlier, this authorization will expire on:

I understand that treatment, payment, enrollment, or eligibility for benefits may not be conditioned on signing this authorization, except where allowed by law. I certify that the information I provided on this form is accurate and that I am the patient or am authorized to act on behalf of the patient.

Fees and Identification

I understand that fees may apply for the preparation, copying, and delivery of medical records in accordance with applicable law and facility policy. I agree to pay allowable charges prior to release unless otherwise arranged.

Additional Instructions

Patient / Authorized Representative Signature

Certification: By signing above I certify that I am the individual whose information is described in this request, or I am authorized to act on behalf of that individual and have the legal authority to request disclosure of the individual's protected health information. I understand that this authorization will remain in effect until the expiration date indicated above or until I provide written revocation as described herein.

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