Medical Record Release
Patient Information (please print)
Patient Name: ____________________________ Date of Birth: ________________________
Address: ______________________________________________________________________
Telephone #: ____________________________ Medical Record #: _____________________
Release Information to
Name/Facility: __________________________________________________________________
Address: ______________________________________________________________________
Information to be Released (check all that apply)
* Clinic Visit Notes * Imaging Reports * Pathology Reports
* Complete Chart * Lab Reports * Other: _________________________
* Discharge Summary * Operative Reports _________________________
Authorization (authorization remains valid for 90 days from date of signature)
Patient Signature: _______________________________________ Date: ________________
Parent/Guardian: _______________________________________ Date: ________________
Authorization for Release of Sensitive Information
This medical record may contain certain sensitive or statutorily protected information.
Please indicate the information you would like released. A separate signature is required.
* Mental Health Information * Social Service Information
* Domestic Violence Information * Sexual Assault Information
* Alcohol/Drug Abuse Information * Sexually Transmitted Diseases
Patient Signature: _______________________________________ Date: ________________
Parent/Guardian: _______________________________________ Date: ________________
HIV Testing and AIDS Treatment
This medical record may contain HIV testing and AIDS treatment information. I authorize the release of this information to the person/facility named in this form, for a single release only.
Patient Signature: _______________________________________ Date: ________________
Parent/Guardian: _______________________________________ Date: ________________
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