Healthcare Medical Reports

HEALTHCARE MEDICAL REPORTS

Patient Information

Date of Birth:    Gender:

Emergency Contact

Insurance Information

Report Request / Scope of Records

Please indicate the specific types of medical reports requested (select all that apply):

Recipient / Purpose of Disclosure

Purpose of Disclosure (select all that apply):

Sensitive Information — Authorization Required

By default, this authorization will include the following categories only if you indicate consent below. Check each category you specifically authorize for release:

Authorization, Limits, and Acknowledgements

I authorize the release of the medical records described above from the treating provider or facility to the named recipient. This authorization specifically permits the release of all medical information necessary to fulfill the requested report types, including summaries, laboratory data, imaging reports, and provider notes, except for any categories I have not selected above.

I understand that information used or disclosed pursuant to this authorization may include information that is privileged or protected under federal or state law. I understand that once disclosed to the recipient, the information may be subject to redisclosure and may no longer be protected by federal privacy regulations.

I understand that I may revoke this authorization at any time by delivering a written revocation to the health information management department of the releasing provider, except to the extent that action has already been taken in reliance on this authorization. Revocation will not affect disclosures made in reliance on this authorization prior to receipt of the revocation.

Unless otherwise revoked, this authorization will expire on: . If no date is provided, this authorization will expire one year from the date of signature.

I acknowledge that the provider may charge a reasonable fee for copying and/or preparing these records in accordance with applicable law. I agree to pay any required fees unless waived by the provider.

Medical Summary (Provider Use / Optional)

Attachments Checklist

Certification and Patient Acknowledgment

I certify that I am the patient named above or am authorized to act on behalf of the patient as the patient's personal representative. I have read and understand this authorization. I understand that signing this form is voluntary and that I may refuse to sign this authorization. By signing below, I authorize the disclosure of the specified medical information as described herein.

HIPAA Acknowledgment: I acknowledge that I have received or been offered a copy of the Notice of Privacy Practices and understand that the information released may be subject to redisclosure by the recipient.

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