MiBella - Release of Medical Records

MiBella - Release of Medical Records
Patient Name*

First NameLast Name
Last Four Digits of Social Security Number *
Date of Birth*

MonthDayYear
Date
The type and amount of information to be used or disclosed is as follows: (include dates where appropriate)

Problem listPatient Account Statement/Billing RecordsList of AllergiesConsultation reportsPatient Account Statement/Billing RecordsMedication ListMost recent history and physicalLaboratory resultsMost recent discharge summaryX-ray and imaging reportsEntire Record
I understand that the information in my health record may include information relating to sexually transmitted disease, acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV). It may also include information about behavioral or mental health services, and treatment for alcohol and drug abuse.
This information may be disclosed to and used by the following individual or organization:
From (Doctor's Name)*
Phone Number
Please enter a valid phone number.
Fax Number
To *
Phone Number*
Please enter a valid phone number.
Fax Number*
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
I understand that I have the right to revoke this authorization at any time. I understand that if I revoke this authorization I must do so in writing and present my written revocation to Sheba Massey, Privacy Officer. I understand that the revocation will not apply to information that has already been released in response to this authorization. I understand that the revocation will not apply to my insurance company when the law provides my insurer with the right to contest a claim under my policy. Unless otherwise revoked, this authorization will expire in six months.
I understand that authorizing the disclosure of this health information is voluntary. I can refuse to sign this authorization. I need not sign this form in order to assure treatment. I understand that I may inspect or copy the information to be used or disclosed, as provided in CRF 164.524 of the Federal Register Rules and Regulations. I understand that any disclosure of information carries with it the potential for an unauthorized redisclosure and the information may not be protected by federal confidentiality rules. If I have questions about disclosure or my health information, I can contact Sheba Massey, Privacy Officer.
Signature of Patient or Legal Representative*

Clear
Date*

MonthDayYear
Date
If signed by Legal Representative, Relationship to Patient *
Signature of Witness*

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Should be Empty: