Authorization for Medical Records

Complete a Medical Record Request
Please let us know what you need to do*

Generate a new request form onlineI have a signed authorization and i just need to send it to ClearPath Family Healthcare
File Restrictions

PDF file format ONLY

MAX file size is 20 MB
Please upload your file here*

Cancelof
What is the patients name?

First NameLast Name
What is the patients date of birth

MonthDayYear
Date
If we have questions, how may we contact you?*

EmailPhone
What is your phone number*
Please enter a valid phone number.
What is your email address?*

Confirmation Emailexample@example.com

Authorization for Medical Records
PART A: Patient Information
Patient full name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.
Email*

Confirmation Emailexample@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

PART C: Manner of Access
How would you like ClearPath Family Healthcare send your records?*

Secure EmailSecure FaxPatient Portal
What email should we use?*
example@example.com
What fax number should we use*
Please enter a valid phone number.
We will process your records and upload them to the portal.

When this upload is complete, please go to https://www.myhealthrecord.com/Portal and login, or check your email for the login link
PART D: Expiration Date
When do you want this authorization to expire?*

12 months6 months3 months1 month

Click to review what you are authorizing
By signing this form, I authorize the release protected health information about me (or another person for whom I have given authority to sign) to the ClearPath Family Healthcare or the clinic or individual listed in part B of this form for the time period, purpose, and extent described above. My signature indicates that I fully understand and acknowledge the following:
- My health record may include information relating to sexually transmitted diseases (STDs), acquired immunodeficiency syndrome (AIDS), human
  immunodeficiency virus (HIV), behavioral or mental health services, blood alcohol and drug testing, and treatment for alcohol and drug abuse.
- The protected health information to be used or disclosed under this authorization may be subject to re-disclosure by the recipient and may no longer be protected under federal law.
- I have the right to refuse to sign this authorization. CP will not condition treatment, payment, enrollment, or benefits eligibility on my signing this authorization.
- I have the right to revoke this authorization in writing at any time to the extent that the use or disclosure has not already been made. I may do so in person at the office where my records are maintained.
- CP may charge a fee for copies of requested health information to cover cost of labor, supplies, and/or postage, if mailed to you. We will inform you of the total charges before providing the requested copies.

Click to view the terms and conditions
Signature*
Date Authorized

MonthDayYear
Date
Should be Empty: