HTML Preview Printable Medical Records Release Form page number 1.
MEDICAL RECORDS RELEASE FORM
1) PATIENT INFORMATION:
_____________________________________________________________________________________________________________________________________
Name Address City State Zip
______________________________ (_________)______________________________ ______________________________________________________
Date of Birth Daytime Phone Previous Name
2) AUTHORIZES:
Providence Women’s Healthcare___________________________________________________________________________________________
Name of Medical Office
1300 Upper Hembree Road, Building 100, Suite D Roswell GA 30076_____ (770) 670-6170 (770) 670-6171________
Address City State Zip Phone Number Fax Number
3a) TO DISCLOSE TO:
□ Self, Delivery Options: □Pick up □ Mail to address above
□To be picked up: I hereby authorize ___________________________________________________________ to pick up my records. (Photo ID required.)
Send to: □ ___________________________________________________________________________________________________________________________
Name of Health Care Provider / Plan / Other
__________________________________________________________________________________ ____________________________________
Address Or Health Care Provider FAX #
3b) TO OBTAIN FROM: __________________________________________________________________________________________________________________
Name of Health Care Provider / Plan / Other
____________________________________________ (_________)______________________________ (_________)______________________________
Address Phone Number Fax Number
4) DATE(S) OF INFORMATION TO BE DISCLOSED/OBTAINED: From _________________ to _______________ If left blank, only information from the
past two (2) years will be disclosed/obtained. (month/year) (month/year)
5) INFORMATION TO BE DISCLOSED/OBTAINED:
□All medical records related to (specify condition, treatment, etc.): ______________________________________________________________________
□Radiology films/images (specify test): ________________________________________________________________________________________________
□Specific records/information as follows: ______________________________________________________________________________________________
_____________________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________________
I DO NOT WANT THE FOLLOWING INFORMATION DISCLOSED/OBTAINED (as defined by applicable state and federal laws):
□Alcohol/Drug Abuse □HIV Test Results □ Mental Health / Developmental Disabilities
6) EXPIRATION: This Authorization is good until the following date / event: ___________________________________________________________
Note: If this item is left blank, the authorization will expire in one (1) year from the date signed.
7) PURPOSE (Check all that apply - copy fees apply) □Transfer of Care □Insurance Eligibility/Benefits □Personal (at my request)
□Other: ______________________________________________________________________________________________________________
8) YOUR RIGHTS WITH RESPECT TO THIS AUTHORIZATION: I am aware that I have the right to inspect and receive a copy of the health information
I have authorized to be used and/or disclosed by this Authorization. I understand that I may be charged a fee for record copies. In addition, I
understand that I do not need to sign this Authorization in order to receive treatment. I also am aware that I may revoke this Authorization by
notifying Providence Women’s Healthcare in writing. However, I understand that my revocation will not be effective as to uses and/or
disclosures: (1) already made in reliance upon this Authorization; or (2) needed for an insurer to contest a claim/policy as authorized by law if
signing the Authorization was a condition to obtaining insurance coverage. I realize that the information used and/or disclosed pursuant to this
Authorization may be subject to re-disclosure and no longer protected by federal privacy law.
9) SIGNATURE OF PATIENT / LEGAL REP: _______________________________________________________ DATE: ________________
If signed by a person other than the patient, complete the following:
1. Individual is: □a minor □legally incompetent or incapacitated □deceased
2. Legal authority: □parent* □legal guardian □next of kin / executor of deceased □activated POA for Health Care
* By signing above, I hereby declare that I have not been denied physical placement of this child.
For Office Use Only:
Signature/ID verified □Yes □No Completed by: __________________________________________ Date released ______________ # of pages__________