Records Release Form

Patient Name
Account #
Former Name (If any)
Daytime Telephone
Format: (000) 000-0000.
Birth Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
INFORMATION TO BE RELEASED FROM
I hereby authorize (name of organization) To release the following medical information contained in patient's medical record. blanks
INFORMATION TO BE RELEASED TO
Name of Physician/Organization Street Address
Name of Physician/Organization
City/State/Zip Phone
Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

City/State/ZipState / Province

Postal / Zip Code
PURPOSE FOR THE REQUEST
Moving
Treatment or consultation
Dissatisfaction
Change of Insurance Plan
At Patients Request
Other (specify)
General Release
TYPE OF INFORMATION TO BE RELEASED

(No information will be released unless a box is checked)
Medical Records/Excluding Protected Records
(This will be limited to 1 year of information including Lab, x-ray reports unless otherwise stated)
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Other Records (specify)
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Information Protected by State/Federal Law
All of my records including: AIDS/HIV and Other Communicable Disease Information, Behavioral Health Care/Psychiatric Care, Alcohol and/or Drug Abuse Treatment
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
THIS AUTHORIZATION WILL AUTOMATICALLY EXPIRE AFTER ONE YEAR

(or 60 days for drug and alcohol abuse records) from the date of signing. The undersigned may revoke this authorization at any time by providing written notice of revocation.

With respect to drug and alcohol abuse treatment, information or records regarding communicable disease-related information, the recipient of this information understands that it is prohibited from making any disclosure of this information unless further disclosure is expressly permitted by written consent of the undersigned or otherwise permitted by applicable law.

I understand that Forward Care Family Practice physicians may not condition my treatment on whether I sign this authorization form unless specified above under Purpose for Request. I can inspect or receive a copy of the protected health information to be used or disclosed. Forward Care Family Practice
Signature of Patient OR Legal Representative
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Please Print Name of Signing Party

First NameLast Name
Should be Empty:

INFORMATION TO BE RELEASED FROM

INFORMATION TO BE RELEASED TO

PURPOSE FOR THE REQUEST

General Release

Information Protected by State/Federal Law