I. PATIENT INFORMATION
- Title: (select one)
- [] Mr.
- [] Mrs.
- [] Ms.
- [] Other
ANSWER
Middle Name: (optional)
ANSWER
Last Name:
ANSWER
Gender: (select one)- [] Male
- [] Female
DD/MMM/YYYY
Address:
ANSWER
ZIP / Postal Code:
ANSWER
II. CONTACT INFORMATION
- Phone Type: (select one)
- [] Mobile
- [] Home
- [] Work
- [] Other
ANSWER
Email:
ANSWER (( Include forum name in brackets ))
III. RELEASE INFORMATION
- Purpose of Medical Information Release:
- [] Further Treatment / Continued Care
- [] Personal Use
- [] Attorney / Client
- [] Other: (specify here)
- Format of Medical Information Release:
- [] Copy of Record to be picked up
- [] Verbal Release (e.g. phone conversation)
- [] Electronical Release (sent via email)
- [] Other: (specify here)
- Date Range:
I authorize the release of information covering the period(s) of treatment:- From: DD/MMM/YYYY
- To: DD/MMM/YYYY
- Medical Records to be Released: (check all that apply)
- [] Emergency Room Visit (ER notes, progress notes, consultations, procedure notes, test results)
- [] Hospital Stay (History and physical, progress notes, consultations, operative reports, discharge summary, test results)
- [] Outpatient Surgery/Procedure (History and physical, progress notes, consultations, procedure notes, test results)
- [] Clinic, Office Visit or Immediate Care (Office notes, progress notes, procedure notes, test results)
- [] Psychology Visits (Office notes, progress notes, procedure notes, evaluation results)
- [] Other Records: (specify here)
- I, [write your full name here], hereby authorize Pillbox Hill Medical Center to disclose my individually identifiable health information. I understand that this authorization is voluntary and I may refuse to sign this authorization. I further understand that my health care will not be affected if I do not sign this form.
I, [write your full name here], understand that if the recipient authorized to receive the information is not a covered entity, the released information may no longer be protected by federal and state privacy regulations.
I, [write your full name here], further understand that I may revoke this authorization at any time by notifying, in writing, the Pillbox Hill Medical Center facility where this authorization is being signed. I also understand the revocation must be signed and dated with a date that is later than the date on this authorization. The revocation will not affect any releases made prior to the receipt of the written revocation.
I, [write your full name here], understand the record might not be complete, if it is a recent visit, and additional documentation could be added after submitting this request.
By typing my name below, I, [write your full name here], certify that this information can be used for the purpose of processing my Authorization for Medical Records Release request. I consider this as my electronic signature for this request.
- Signature:
ANSWER
Date:
DD/MMM/YYYY
