Outbound - Medical Records Release/Request
Patient Name
*
First Name
Last Name
Patient Date of Birth
*
-
Month
-
Day
Year
Date
Name of new doctor/medical office
*
Address of new doctor/medical office
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number of new office
Fax Number of new office
Requesting:
*
Complete medical record
Immunization record only
Other
My reason for disclosure:
*
Transfer of care to new provider
Consultation only from a new provider
Precertification /verification of insurance
Immunization record only
Disclosure of confidential information: please check all that apply
*
I consent to the disclosure of medical information that may include chemical or alcohol dependence or psychiatric care including ADHD, mood or thought disorders.
I consent to the disclosure of medical information that may include blood tests that have been done to detect antibodies to or levels of HIV which is the probable cause of AIDS (acquired immune deficiency syndrome).
This authorization will expire 60 days from today’s date:
-
Month
-
Day
Year
Date
Name of Parent or Guardian (or Adult Patient)
*
First Name
Last Name
Signature
*
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