Patient’s Full Name
Street Address
City
State
Zip Code
Date of Birth
Phone Number
At the request of the individual, I , do hereby authorize the release of: DISCHARGE SUMMARYHISTORY & PHYSICALPROGRESS NOTESOPERATIVE NOTESPATHOLOGY REPORTSLABORATORY REPORTSRADIOLOGY REPORTSECG/EEG/CARDIAC CATHEMERGENCY REPORTSOTHER
I DO authorize release of information related to AIDS (Acquired Immunodeficiency Syndrome) or HIV (Human Immunodeficiency Virus) Infection, psychiatric care and/or psychological assessment, and treatment for alcohol and/or drug abuse.I DO NOT authorize release of information related to AIDS (Acquired Immunodeficiency Syndrome) or HIV (Human Immunodeficiency Virus) Infection, psychiatric care and/or psychological assessment, and treatment for alcohol and/or drug abuse.
INFORMATION RELEASE TO: Name of Company/Agency/Facility/Person
Fax Number
PURPOSE OF DISCLOSURE: REFERRAL TO SPECIALISTLEGAL INVESTIGATIONINSURANCEDISABILITY DETERMINATIONWORKERS COMPPERSONALCHANGE OF DOCTOROTHER
I hereby authorize disclosure of the health information for the above named patient. This authorization is valid for 12 months from the date of signature. I understand that I may cancel this request with written notification but that it will not affect any information released prior to notification or cancellation. I understand that the information used or disclosed may be subject to re-disclosure by the person or class of persons or facility receiving it, and would then no longer be protected by federal regulations. I understand that the medical provider to whom this is authorized is furnished may not condition its treatment of me on whether or not I sign the authorization.
Signature of individual or guardian or Personal Representative of patient’s estate (please use your mouse or finger to sign in the blank space below):
Date
NOTE: HealthPort has been contracted to provide the service of processing medical records requests. Currently, the charge is $0.75 (1-25 pages) $.50 (26-100) $0.25 (101+) plus actual postage. Prices are subject to change without further notice. For further information on pricing, please contact HealthPort at 1-877-595-9900.