Healthcare Request Paperwork

HEALTHCARE REQUEST PAPERWORK

Patient Information

Date of Birth:    Gender:

Emergency Contact

Insurance Information

Request Details

Request Type (check all that apply):

Release of medical records
Request appointment / scheduling
Referral to specialist
Prescription refill request
Other (describe below)

Purpose of disclosure (check all that apply):
Treatment
Payment / Billing
Legal
Personal use

Records to be disclosed (check all that apply):
Entire medical record
Laboratory results
Imaging / Radiology reports
Operative / Procedure reports
Mental health notes (authorize only if specifically checked)
Substance use treatment records (authorize only if specifically checked)
HIV/AIDS-related records (authorize only if specifically checked)

Date range for requested records: From to

Medical History (summary)

Authorization and Notices

I hereby authorize the release, disclosure, or transfer of the identified health information to the recipient(s) designated in this request for the purposes indicated above. I understand that:

• This authorization includes records relating to the conditions and services specified above and will include sensitive information only if specifically checked and initialed below.
• I may revoke this authorization at any time by submitting a written revocation to the releasing facility; revocation will not apply to information already released in reliance on this authorization.
• Information disclosed pursuant to this authorization may be subject to redisclosure by the recipient and may no longer be protected by federal privacy regulations.
• I understand that there may be administrative fees for copies or retrieval of records and that refusal to sign this authorization will not affect my ability to obtain treatment, payment, enrollment, or eligibility for benefits unless the authorization is for records necessary to determine those matters.

If authorizing disclosure of mental health, substance use treatment, or HIV/AIDS status, I acknowledge that I have specifically checked those boxes above to permit release of those categories.

Authorization expiration: This authorization will expire on , or upon completion of the request, whichever occurs first.

HIPAA Privacy Acknowledgment

By signing below, I acknowledge that I have received or been offered the Notice of Privacy Practices describing how medical information about me may be used and disclosed and how I can access this information.

I acknowledge receipt of the privacy notice

Certification

I certify that the information provided on this form is true and correct to the best of my knowledge. I authorize the person(s) and organizations named on this form to disclose the protected health information described herein to the recipient(s) indicated. I understand that a copy or facsimile of this authorization has the same force and effect as the original.

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