Personal Medical Records Release Form



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How to write a Personal Medical Records Release Form? Download this Personal Medical Records Release Form template that will perfectly suit your needs.

Our collection of online health templates aims to make life easier for you. Our site is updated every day with new health and healthcare templates. By providing you this health Personal Medical Records Release Form template, we hope you can save precious time, cost and efforts and it will help you to reach the next level of success in your life, studies or work!

SSM Health “Request for Access to/Authorization for Use and Disclosure of Protected Health Information” Name of SSM Health Entity maintaining the information that is subject to this Authorization: PATIENT NAME: LAST FIRST MI Maiden or Other Name DATE OF BIRTH:-- FORMER NAME: MEDICAL RECORD MO DAY YR ADDRESS: CITY:STATE:ZIP: DAY PHONE: EVENING PHONE: Type of access requested:  Inspection  Hard Copy  Electronic Copy (only available if SSM Health maintains the requested information electronically) To Disclose My Protected Health Information To: I Hereby Authorize: NAME ADDRESS CITY, STATE ZIP PHONE FAX NAME Relationship ADDRESS CITY, STATE ZIP PHONE FAX METHOD OF DELIVERY OF RECORDS (please select one):  Mail  Hold for pick up by:  Electronic (records will be provided on a CD and mailed to your residence) INFORMATION TO BE RELEASED: DATES:         I specifically authorize the release of information relating to: Discharge Summary  Substance abuse (including alcohol/drug abuse) History Physical Exam Progress Notes  Mental health or behavioral health Lab Reports  HIV related information (AIDS related testing) X-Ray Reports X Medication Records SIGNATURE OF PATIENT OR PERSONAL REPRESENTATIVE DATE Detailed Bill Other (specify content and dates): PURPOSE OF DISCLOSURE:     Changing physicians  Consultation  Insurance/Workers’

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