Sunrise Medical - Medical Records Request

Name

First NameLast Name

Date of Birth

Your Phone Number

Area CodePhone Number

Your Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Requesting Records from:
Phone Number:   Area Code   Phone Number.
Fax Number: Area Code   Phone Number.

Sending Records to:
Phone Number:   Area Code   Phone Number.
Fax Number: Area Code   Phone Number.

Please Select the Records you are Requesting

I understand that medical information may include if applicable: Alcohol and/or drug abuse and/or mental health treatment information protected under the regulation in Title 42 of Code of Federal Regulations Part II. Information about Human Immunodeficiency Virus - HIV, acquired immunodeficiency syndrome - AIDS, and AIDS related complex - ARC, as defined by Department of Public Health rules (1989 Public act 174), third party Information. I understand that I may revoke this authorization at any time by notifying Sunrise Medical Associates in writing, otherwise, it will remain in effect for a period of 12 months from the date signed. This authorization pertains to fulfillment of the above stated purpose(s). Covered entity will not condition treatment, payment, enrollment or eligibility. I understand that information disclosed pursuant to the authorization may be subject to re-disclosure by the recipient and no longer protected by HIPAA's privacy rule protections.

I have read the above, and acknowledge that I am familiar with and fully understand the terms and condition of this authorization.

Your Signature to Authorize this Request

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Sunrise Medical Center Medical Records Request