Medical Record Release Authorization
I. PATIENT INFORMATION
Full Name: Efrain Abshire
Age: 40
Address: Shreveport, LA 71101
Phone Number: 222 555 7777
Email Address: efrain@you.mail
II. RECORDS TO BE RELEASED
Please check the appropriate box for the medical records you wish to release:
Type of Record | Check Box |
|---|
Medical History | |
Treatment Records | |
Lab Results | |
Prescription Information | |
Immunization Records | |
Radiology Reports | |
Other (Specify): [N/A] | |
III. RELEASE TO
Recipient Name: Dr. Alice Johnson
Address: Shreveport, LA 71101
Phone Number: 222 555 7777
Fax Number: 222 555 7777
IV. PURPOSE OF DISCLOSURE
Please check the appropriate reason for the release of medical records:
Reason | Check Box |
|---|
Personal Use | |
Insurance Purposes | |
Legal Purposes | |
Employment | |
Other (Specify): [N/A] | |
V. AUTHORIZATION
By signing below, I authorize the release of my medical records as specified above. I understand that I have the right to revoke this authorization at any time by notifying [YOUR COMPANY NAME] in writing. This authorization is valid until 12/31/2081 unless I specify otherwise.
Efrain Abshire
Date of Signature: 12/03/2081
Relationship to Patient (if applicable): N/A
VI. CONFIDENTIALITY NOTICE
The information provided under this authorization will be kept confidential as per the guidelines of HIPAA and other applicable laws. The information may not be disclosed to anyone other than the named recipient unless specifically authorized by law.
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