Healthcare Medical Records Review

HEALTHCARE MEDICAL RECORDS REVIEW

Patient Name:   Date of Birth:

Patient Information

Insurance Information (if applicable)

Medical History (brief)

Records Requested

Please select the records and services requested for review or copy. Checking a box authorizes review of those specific records maintained in the medical chart.

Complete medical record    Consultations    Imaging reports (X-ray, MRI)    Laboratory results

Operative reports    Billing records    Progress notes    Mental health/behavioral health (see limitations below)

Date range for records requested: From through

Purpose of Review

Personal review    Second opinion    Legal    Insurance claim/appeal

Continuity of care    Research/education    Other (specify)

Release / Review By

Records will be reviewed by: Relationship/Title:

Release to third party? Yes    No

Method of Review / Delivery

In-person review at provider facility    Electronic copy (portal or encrypted file)    Paper copy mailed to address on file

Privacy, Limitations, Fees and Revocation

I authorize the health care provider named below to permit review and disclosure of my medical records as specified above. I understand that records disclosed pursuant to this authorization may include sensitive information, including but not limited to substance use treatment, communicable disease testing or results, and genetic information where such records exist, unless specifically excluded below.

Exclusions (check all that apply): Exclude psychotherapy notes    Exclude records related to substance use treatment    Exclude HIV/AIDS-related testing or treatment records

I acknowledge that the provider may impose reasonable fees for copying, postage, or administrative costs in accordance with applicable law and that such fees must be paid prior to release of copies unless otherwise agreed in writing. I understand that the provider may require verification of identity before permitting review or release of records.

I understand that I may revoke this authorization at any time by submitting a written revocation to the provider, except to the extent the provider has already acted in reliance on this authorization. Revocation will not affect disclosures made prior to receipt of the revocation.

HIPAA / Privacy Acknowledgment

By signing below, I acknowledge that I have read and received the provider's Notice of Privacy Practices or otherwise had the opportunity to do so. I understand that information disclosed under this authorization may be subject to re-disclosure by the recipient and may no longer be protected by federal privacy law.

I certify that the information provided on this form is true and correct and that I am the patient or the legally authorized representative of the patient with authority to sign this authorization. I understand that a copy or facsimile of this authorization has the same force and effect as the original.

Provider / Record Location (for completion by provider)

Sign Now