Medical Release Form - Altoona OB/GYN

Patient Authorization To Release Medical Records

Name(Required)

First Last

Social Security #(Required)

Date of Birth(Required)

Address(Required)

Street Address City State ZIP Code

I authorize(Required)

(Name of Physician, Practice, Facility, etc.)

to provide(Required)

(Name of Physician, Practice, Facility, etc.)

The information to be released is (state specific documents, time period, etc):(Required)

Purpose or need for the information requested:(Required)

When my information is used or disclosed pursuant to this authorization, it may be subject to redisclosure by the recipient and may no longer be protected by the federal HIPAA Privacy Rule.

I understand I may refuse to sign this authorization. If I refuse, the identified records will not be disclosed. Whether I sign or refuse to sign, my treatment will not be affected.

I understand also that I may revoke this authorization, in writing at any time except to the extent that action has been taken in reliance thereon. This consent will remain in effect no more than ninety (90) days from the date I signed this Authorization in order to accomplish its purpose.

Patient/Parent/Legal Guardian Signature(Required)

Date(Required)

Relationship(Required)

Witness Signature(Required)

Date(Required)

I understand that my medical records may contain alcohol/drug abuse, mental health information, HIV results and/or STD testing results. I give special authorization to the health care provider/facility to release this information in my records to the person, physician, facility named above for the stated purpose.

I have read this form, or had it read to me and understand the content. I was give the opportunity to as questions and have them answered to my satisfaction.

Patient/Parent/Legal Guardian Signature(Required)

Date(Required)

Relationship(Required)

Witness Signature(Required)

Date(Required)

If signed by other than patient, state relationship and reason for patient's inability to sign.(Required)

This field is for validation purposes and should be left unchanged.