Medical Records Release

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Medical Records Release - Page 9 of 9

HIPAA COMPLIANT AUTHORIZATION FOR THE RELEASE OF PATIENT INFORMATION

Records to be released from: ( Physician or Company )

New Patient Info (Continued...)

Today Date

Medical Records Release

Records to be released from: ( Physician or Company )

Full Address

Phone / Fax Number

Patient Information

Patient Fullname

Patient Dob

Patient Last4

Authorization

I authorize and request the disclosure of all protected information for the purpose of review and evaluation from the above-named doctor or healthcare provider to:

Requesting Provider

Requested information (if more than 25 pages, please mail):

8550 SW HWY 200, Ocala, FL 34481

Need Dates From

Need Dates Until

Records to Inlcude:

All records

Office visit notes-last two only

Office visit notes-ALL

Cardiology reports only

Lab reports only

Radiology reports only

Hospital records only

Consult notes only

Other Records (Please specify)

Authorization

Authorization: I certify that this request has been made voluntarily and that the information given above is accurate to the best of my knowledge. This authorization will automatically expire upon satisfaction of the need for disclosure or if revoked in writing by the patient. I understand that a copy of this authorization may be used with the same effectiveness as an original.

HIPAA REQUIRED STATEMENTS: I understand the following:

I have a right to revoke this authorization in writing at any time, except to the extent information has been released in reliance to this authorization.
The information released I response to this may be re-disclosed to other parties.
My treatment or payment for my treatment cannot be conditioned on the signing of this authorization.

Signature

Patient Signature

Clear

Date Signed

Legal Representative

Auth Name

Relationship

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