logo color FormHeader ReleaseAuthorization
* = required field
Please be aware that there is a charge per page of medical records given directly to the patient.
Please allow 5-10 days for records to be copied. Thank you.
PATIENT INFORMATION
Name of Patient *Date of Birth *
AddressCityStateZipPhone
Release and Send my Medical Records TO – or – Obtain my Medical Records FROM
NameChoose onePhysicianPatientAttorneyInsurance Company
AddressCityStateZipPhoneFax
This authorization is for the release of records pertaining to (check all that apply):
Entire Record Office Visit Notes Care and Treatment for Dates fromto
On Site Record Review by Patient Financial Records Marketing (Financial compensation is received for this request.)
Psychotherapy Notes—if this box is checked, only psychotherapy notes may be released.
Other as Listed
Reason for Releasing Records (check all that apply):
Moving Insurance Providing copy to Primary Care Physician Dissatisfaction with Practice
I intend to transfer my care to another practice Other
I would like my records to be (choose one): Faxed (limit 10 pages) Mailed Picked Up
This authorization shall be in effect until the information has been forwarded as requested or until the course of treatment is complete.
PATIENT RIGHTS
  • I have the right to revoke this authorization at any time.
  • I may inspect or copy the protected health information to be disclosed as described in this document.
  • Revocation is not effective in cases where the information has already been disclosed but will be effective going forward.
  • Information used or disclosed as a result of this authorization may be subject to re-disclosure by the recipient and may no longer be protected by federal or state law.
  • I may refuse to sign this authorization and that my treatment will not be conditioned on signing.
  • I understand released information may include a communicable disease diagnosis such as HIV as well as diagnosis of alcohol/drug abuse or mental health.
Signature of Patient or
Personal Representative
  Date
*Description of Personal Representative’s Authority
For Office Use Only: Doctor’s Signature: __________________________________ Date: ________________
Records Release Completed by: ______________________________ Date: ___________ FaxedMailedGiven to Patient