Authorization to Release / Request Medical Records

Name of person making the request *

Today's Date. * +

Relationship to Patient. *

If other, describe. *

If requesting on behalf of the patient, please upload a signed Release of Information signed by the patient or parent / guardian.

Patient name. *

Patient's Date of Birth. * +

Sponsor SSN. *

Name of physician, facility, person, agency, etc requesting records. *

Phone Number *

How do you want the records delivered? *

Fax Number *

Street Address *

Address Line 2

City *

State *

Zip Code *

Email address. *

State the documents to be released and time frame. *

Purpose of Information. *

In order to continue through this form, you must read and acknowledge the next few paragraphs. *

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I understand this consent is voluntary and that I may revoke this authorization at any time (except to the extent that action based on this consent has already been taken) by signing and dating below. This consent will remain in effect no more than thirty (30) days from the date I signed this consent. I also understand that my medical records may include mental health information, drug/alcohol information and/or HIV information. When my information is used or disclosed pursuant to this authorization, it may be subject to re-disclosure by the recipient and may no longer be protected by the federal HIPAA Privacy Rule. I understand I may refuse to sign this authorization. If I refuse, the identified records will not be disclosed. Whether I sign or refuse to sign, my treatment will not be affected.

I have read the above paragraph. *

Yes

Generally, for behavioral health records, only a summary of care is provided. Records requested by a medical facility for continuity of care will be sent at no cost. All others requesting records, to include the patient, are charged a flat fee of $25 per requested record and will be collected prior to the release of the records. Payment can be made by cash, check or charge either in person or over the phone.

I have read the above paragraph. *

Yes

Please allow up to two (2) weeks depending on the amount of records requested. We will contact you when the records are ready.

I have read the above paragraph. *

Yes

By signing below you authorize Family Care Center to provide / request medical records to or from the agency or person listed above. *

clear

To revoke this Authorization to Release / Request Medical Records you must come into the office and sign this document.