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   Release of Medical Records


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Release of Medical Records

Patient

Name: _________________________________ Patient ID: _________________________________
Phone: _________________________________ Email: _________________________________
Address: _________________________________

Transfer From

Doctor: _________________________________ Clinic: _________________________________
Fax: _________________________________ Email: _________________________________
Phone 1: _________________________________ Phone 2: _________________________________
Address: _________________________________

Transfer To

Recipient: _________________________________ Company: _________________________________
Fax: _________________________________ Email: _________________________________
Phone 1: _________________________________ Phone 2: _________________________________
Address: _________________________________

Authorized Information to Disclose

Release of Records

Surgeries/Operations
Diagnoses
Prescriptions/Medications
Alternative Treatments
Mental Health Records
Alcohol/Drug Use Treatments
Sexual Health Records
Other:___________________

Method of Transfer

Release of Dental Records

Fax
Email
U.S. Mail
Other:___________________

Reasons for Disclosure

Release of Records

Legal Requirement
Insurance Claim or Dispute
New Care Provider
Specialist Consultation
Second Opinion
Other:___________________

I, the patient, understand that I may revoke my consent, in writing, at any time. I understand that my information will be held in the strictest confidence and will be read, shared, and held by no parties other than those who transfer the information and those who receive it.

_________________________________________
(Patient's Signature)

_________________________________________
(Doctor's Signature)

_________________________________________
(Date)

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