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Request and Authorization to Copy or Release Health Information
Request and Authorization to Copy or Release Health Information
Request and Authorization to Copy or Release Health Information
Patient Name:
First
Middle
Last
Phone Number
(Required)
Birth date:
MM slash DD slash YYYY
Address:
Street Address
City
State / Province / Region
ZIP / Postal Code
RECIPIENT AND PURPOSE:
Information is delivered to me , the patient.
If this health information is not being delivered to me, then deliver to:
Street Address
Name of Facility / Organization
Street Address
City
State / Province / Region
ZIP / Postal Code
Fax:
The purpose of this Disclosure:
For continuing medical care
For legal purposes
For personal use
For Social Security/Disability
Others
Please check the appropriate box:
CD Pick up - Name of person /Office picking up CD:
TITLE
Type of Imaging Needed
Date of Service
MM slash DD slash YYYY
Date of Pick up
MM slash DD slash YYYY
CD to be mailed (See Box "||" for additional info needed)
Untitled
CD to be sent via FED-Ex, UPS, Cert, Mail, (Etc.) ID Tracking #
Untitled
Send via Courier - Office / Physician name:
First
Electronic transmission to Patient / Physician Email:
Signature of Patient or Personal Representative
(Required)
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Date
MM slash DD slash YYYY
*Name of Personal Representative (if applicable)
First
*The Name of Personal Representative (if applicable) is the patient’s decision maker. It can be the parent if the patient is a minor, legal guardian, health care surrogate, or other person.
Relationship to patient
First