Healthcare Medical Records Request

MEDICAL RECORDS REQUEST / AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION

Patient Information

Patient Name:

Date of Birth:    Gender:    Medical Record / ID #:

Recipient of Records (To Whom Records Will Be Sent)

Records Requested

Dates of Service / Records Requested From: to

Select record types to be released:

Entire Medical Record (excluding psychotherapy notes unless specifically authorized below)

History & Physical

Operative / Procedure Reports

Laboratory / Pathology Reports

Imaging / Radiology Reports and Images

Billing / Account Records

Nursing Notes

Sensitive information (require explicit authorization):

Psychiatric / Mental Health Records

Psychotherapy Notes (if applicable) — I specifically authorize release

Substance Use Disorder Treatment Records

HIV/AIDS Test Results / Records

Purpose of Disclosure

Purpose (check all that apply):   Treatment & Continuity of Care   Insurance/Claims   Legal Purposes   Personal Use / Patient Copy

Method of Disclosure & Fees

Method: Mail   Fax   Pick-up in Person   Secure Electronic Transmission   Unencrypted Email (consent below required)

Fees: I understand that a reasonable fee may be charged for copying and postage. Payment responsibility:

Authorization, Limitations, and Notices

Authorization: I hereby authorize the disclosure of my protected health information as described above. This authorization is voluntary. I understand that my treatment, payment, enrollment, or eligibility for benefits will not be conditioned on signing this authorization.

Right to Revoke: I understand I may revoke this authorization at any time by notifying the releasing facility in writing, except to the extent that action has already been taken in reliance on this authorization.

Redisclosure: I understand that the information disclosed pursuant to this authorization may be subject to redisclosure by the recipient and may no longer be protected by federal or state privacy laws.

Limitations: This authorization does not authorize the release of information created after the date signed unless specifically requested. I understand that certain types of information (e.g., psychotherapy notes, substance use disorder treatment records, HIV-related information) require specific authorization, indicated above.

This authorization will expire on:   or upon the occurrence of:

If you consent to unencrypted email transmission, check below and acknowledge risks (may include interception by third parties).

I certify that I am the patient named above or am the patient's legal representative and have the authority to execute this authorization. I further certify that the information I have provided is true and correct.

I acknowledge receipt of the facility's notice of privacy practices where required, and that I understand my rights regarding this release.

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