Person/Company

Address

City

State StateAlabamaAlaskaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

Zip

Phone (XXX-XXX-XXXX)

Fax (XXX-XXX-XXXX)

From Clinic/Hospital: (Where are the records coming from)

Patient Name

Patient Phone (XXX-XXX-XXXX)

Patient Email (name@website.com)

Date of Birth (mm/dd/yyyy)

Dates of Service (Check One and Complete Dates of Service if Required) Dates of Service (Check One and Complete Dates of Service if Required) Please provide a complete copy of my file for all dates of service Please provide a complete copy of my file for service from:

Service Start Date (mm/dd/yyyy)

Service End Date (mm/dd/yyyy)

Records to be Released (45 CFR § 164.508(c)(1)(i)). Records to be Released (45 CFR § 164.508(c)(1)(i)). All Medical Records Emergency Room Record Lab/Pathology Reports Itemized Billing History & Physical Operative Report Radiology Reports Consultation Reports Discharge Summary Images

Records other Records other Other (please specify)

Other

Purpose for Disclosure Purpose for Disclosure Disability Referring Physician Insurance Patient Request Attorney Other (please state reason)

Other

Please indicate your acceptance by checking the following boxes Please indicate your acceptance by checking the following boxes I understand that I may revoke this authorization in writing at any time except to the extent that action has been taken in reliance upon this authorization (45 CFR § 164.508(c)(2)(i)).

I understand that treatment or payment cannot be conditioned on my signing this authorization, except in certain circumstances such as for participation in research programs, or authorization of the release of testing results for pre-employment purposes (45 CFR § 164.508(c)(2)(ii)).

I understand that my records are confidential and cannot be disclosed without my written authorization except when otherwise permitted by law. Information used or disclosed pursuant to this authorization may be subject to redisclosure by the recipient and no longer protected.

I Understand that the specified information to be released may include, but is not limited to: history, diagnosis, and/or treatment of drug or alcohol abuse, mental illness, or communicable disease, including Human Immunodeficiency Virus (HIV) and Acquired Immune Deficiency Syndrome (AIDS) (45 CFR § 164.508(c)(2)(iii)).

Date (mm/dd/yyyy)

Electronic Signature of Patient or Legally Authorized Representative