patient-auth-for-rc-to-release-med-records

Patient authorization for copy and release of records from Henry Fertility.

I,

(Name of Patient)

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

(Date of Birth)

Date

(SS #)

(Patient E Mail Address)

example@example.com

Hereby authorize Henry Fertility to copy and release my health information to:

Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Please enter a valid phone number.

FAX Number

Please enter a valid phone number.

This protected health information is being released for the following purposes:

Moving/relocatingChanging physicians (i.e. Release to OB/GYN)For PCP’s recordsOther

If "Other" was selected above, please list specific prupose:

Please state what portion of your health information record you would like copied and released; for example,

Please state what portion of your health information record you would like copied and released:

A.) Complete medical recordB.) Partial medical recordC.) Other

If B.) "Partial medical record" was selected above, please state pregnancy-related information from enter date toenter date .

Copying Fees: Henry Fertility will forward your records to a physician one time at no charge. All additional requests will incur a $20 copy fee. Henry Fertility will charge a $20 copying fee to all requests made by a patient to obtain records for their personal use.

Please note we may only release records for services provided with Henry Fertility. Records will be sent out within 30 days of receipt of this request. If you have not been seen within the past 5 years and your chart is in storage, records will be sent out within 60 days. This consent expires 60 days from the date signed.

(Signature)

Clear

(Date)

Date

Please verify that you are human*