Authorization for Disclosure of Protected Health Information
Please follow all instructions for completing this form:
- Print legibly in ALL fields using blue or black ink.
- Fill out name or facility to whom you want to RELEASE the patient information.
- Date of Admission/Treatment is REQUIRED. Specify what date(s) of service to be released (e.g: April-May 2008; all dates of service; etc.)
- Mark the appropriate box for each item to be disclosed (e.g., lab reports; radiology; discharge summary; emergency department.) If you would like all items for the date of service listed, check “Others” and write in “All Records”.
- In the space after: “The information will be used for the following purposes:”, please state why you want the information released. (e.g.: personal use; continued care; insurance claim, billing, etc.)
- In the section labeled: “This authorization will remain in effect”, indicate an expiration date for the release. Check the box to list a dare or list an event, e.g. records are sent.
- Signature required. If you are a personal representative for the patient, you must state your relationship to the patient, such as legal guardian, power of attorney, care provider, etc. Photo identification and proof of authority is required to receive all medical records.
All fields must be completed before we can process your request.
- First 10 Pages are Free
- Black and White copies after the first ten pages: $.50 per page
- Radiology Images on CD – Call for pricing
Depending on the amount of information requested and the medical significance, Medial Releases of Information may take 1-5 days but no longer than 30 days.
With questions regarding the release of your medical records, please give us a call.