Medical Records Release Request

1Get-Started

2Medical Records

3Patient Details

4Request Provider

5Final Details

Where will you use the Medical Records Release Request?

Location

CountryState

Patient Information

What is the Patient's name?

Name:

Date

Address:

e.g.(Street, City, State and Zipcode)

What is your relationship to the Patient?

Parent

Legal Gaurdian

Attorney

Other

Other Relationship:

What is your name and address?

Name:

Date

Address:

e.g.(Street, City, State and Zipcode)

Personal Information

What is your name and address?

Name:

Date

Address:

(e.g. Street, City, State, Zip Code)

Another name as records

What other name might the records be filed under?

Name

Doctor's details

Who is the doctor being asked to release the medical records?

Name

Clinic Name

Address

e.g.(Street, City, State and Zipcode)

Patient status as a current or former patient

Are you a former or current patient of the Provider?

Current patient

Former patient

Medical information

What medical information may be released?

All information INCLUDING substance abuse, mental health, or HIV-AIDS information

All information EXCEPT one or more of the following: substance abuse, mental health, or HIV-AIDS information

Only specific medical information

Which medical information should NOT be released?

Substance abuse treatment (drug or alcohol)

Mental health treatment

HIV or AIDS

Other medical information

What other information, should NOT be released?

What specific medical information may be released?

Authorization expire

When will this Authorization expire?

One year

Month

Enter Month(s):

Please enter a number from 1 to 12.

e.g.(1,2)