Request to Obtain Medical Records

Patient:

First NameLast Name

Date of Birth:

Date

Patient's Phone Number:

Please enter a valid phone number.Format: (000) 000-0000.

Patient's Email Address:

example@example.com

Patient's Home Address:

Street Address

Street Address Line 2

CityState

Zip Code

I hereby authorize the release of the following Protected Health Information to or from WellCareMedical Clinic: Psychiatric Evaluation and Mental Health Treatment Records (Excludes psychotherapynotes, which require a separate authorization). Substance Use Disorder Management/Treatment Records (including any information ondrug or alcohol addiction/abuse; explicit consent required under 42 CFR Part 2). Primary Care Medical Diagnosis and Treatment Records. Medications Prescribed. Other(Specify).

To/From (Name of Facility or Individual to be released to?)

Phone Number of Facility or Individual to release information to/from:

Please enter a valid phone number.Format: (000) 000-0000.

Fax:

Please enter a valid phone number.Format: (000) 000-0000.

Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

I understand that by signing below, I am authorizing the release of all or part of my Psychiatric Mental Health, Internal medicine (primary care) or Substance Abuse management and treatment record for the purpose of my treatment and/or pertinent healthcare information as determined by my provider. This release may include records containing information regarding the medical diagnosis and/or treatment of mental illness, and/or drug, and/or alcohol addiction, or abuse to any person, persons, and/or agency listed on this form.

Expiration: This authorization expires on _____________ (MM/DD/YYYY, no later than one year from signature date) or upon the following event: ___________ (e.g. end of treatment at WellCare Medical Clinic). If no date or event is specified, it expires one year from the date of signature.

Purpose of the Release or Use of Health Information:  Healthcare  Research  Marketing  Legal  Other (Specify): ________

Authorization Information: 1. I authorize the use of disclosure of Protected Health Information as described above for the purpose indicated until such event or time as specified above. 2. I have the right to revoke this authorization. To do so, I understand that I must submit my revocation in writing to the party specified above to receive my health information. The revocation will prevent further disclosure of my health information from the date of receipt. I understand a delay may exist if the party specified above to receive my health information is not the covered entity authorized to disclose Protected Health Information to the party specified above. I also understand that a written revocation is not effective with respect to any actions the covered entity or party took in reliance on a valid Authorization, or where the Authorization was obtained as a condition of obtaining insurance coverage. 3. I am signing this authorization voluntarily and understand my entitlement to treatment, payment, enrollment, or eligibility for health plan benefits will not be affected if I do not sign this Authorization. 4. If the party specified above to receive my health information is not a HIPAA Covered Entity or Business Associate as defined in 45 CFR Section 160.103, the disclosed health information may no longer be protected by federal and state privacy regulations. 5. I have a right to receive a copy of this Authorization form.” I understand that by signing below, I am authorizing the release of all or part of my Psychiatric Mental Health, Internal medicine (primary care) or Substance Abuse management and treatment record for the purpose of my treatment and/or pertinent healthcare information as determined by my provider. This release may include records containing information regarding the medical diagnosis and/or treatment of mental illness, and/or drug, and/or alcohol addiction, or abuse to any person, persons, and/or agency listed on this form.

Signature

Name

First NameLast Name

Date

If signed above for patType a questionient under the age of 18 LIST NAME & RELATIONSHIP TO PATIENT:

Name of translator (if applicable). Signature of translatory (if applicable).

Release of Medical Records