Authorization for Release of Medical Records
Name of Client
*
First Name
Last Name
Birth Date
*
Please select a month
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February
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Month
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Day
Please select a year
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Year
Name of Person Completing Form (if different than client):
First Name
Last Name
Relationship to client if person completing form is not client
Email
*
example@example.com
Last 4 SSN of Client
*
Type of Information to be Released
*
(List as specifically as possible, for example: name, dates of service, any documents).
Purpose for Information Release
*
(List as specifically as possible, for example: to receive benefits).
Release Information to the Following
Name
*
First Name
Last Name
Fax Number
*
Email Address
*
Delivery Method
*
Please Select
Encrypted Email
Mail - USPS
Fax
Records are being request for the following purpose:
*
Continued Medical Care
Legal Purposes
Insurance Purposes
Personal Interest
Other
Where records should be sent (if being mailed):
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Release Date Expiration (recommendation is one year past today's date but cannot be longer than two years past today's date)
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Consent
*
I understand that this release is valid when I sign it and that I may withdraw my consent to this release at any time either orally or in writing.
Consent
*
I understand that there is no charge for my records to be sent electronically by secure email. However, I will be charged $15 for the first 10 pages and $.50 for each additional page if I request that my records be mailed to me or to someone else.
Consent
*
I understand that if I choose to have my records sent electronically via encrypted email, there is a risk that electronic communications may be compromised, unsecured, and/or accessed by a third party despite Creekside sending such records in a secure and encrypted format. If I chose this format, I acknowlege those associated risks.
Signature
*
Submit Form
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