Authorization to Release or Obtain Confidential Health Care Information

Authorization to Release or Obtain Confidential Health Care Information
Date Today *

Month Day Year
I, hereby authorize Richmond Spine Interventions & Pain Center to release/obtain the health information indicated below contained in my patient records to/from the recipient named below.
Information Requested For:
Patient *

First Name Middle Name Last Name
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Date of Birth *

Month Day Year
Phone Number *

Area Code Phone Number
Information to be *

Released To Obtained From
Name *
Person/Provider/Facility/School/Attorney etc.
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number

Area Code Phone Number
Fax

Area Code Phone Number
Information to be *

Released To Obtained From
Medical Records *

Radiology Images Radiology Reports Laboratory Reports Pathology Reports Office/Procedure Notes Other
Use the space for other *
Records to be Delivered by: *

Mail copies to address above Fax To be picked up
To be picked up by(full name):
Indicate relationship:

Parent Legal Guardian
Signature *
Printed Name of Person Signing *
Date *

Month Day Year
This form may be used to obtain or request information from another facility for continuity of care and does not require patient authorization.

www.RichmondSpinePain.com
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