Medical Records Request ****Dr. Burgin Patients Only*****

8383 Millicent Way (318) 797-6661

Shreveport, LA 71115 Fax (318)795-8512

AUTHORIZATION TO DISCLOSE PERSONAL HEALTH INFORMATION
Printed Name of Patient
Previous Names, If Applicable
Date of Birth

Month Day Year
Date
Daytime Phone Number
SEND INFORMATION TO: (please be specific)
Provider Name/Organization
Address
Phone

Area Code Phone Number
Fax#
INFORMATION TO BE RELEASED FROM: (please be specific)
Provider Name/Organization
Address
Phone

Area Code Phone Number
Fax#
PURPOSE OF DISCLOSRE: Transfer of care
Medical Records from last 2 years
If the patient is unable to sign, please indicate such and the authority to act of the person whoissigningfor the patient.This formmust be dated within 90 days of receipt, and may be revoked at any time, providing the information has not already been disclosed. Please see our Notice of Privacy Practices for instructions as how to revoke authorization. We will not condition treatment on the completion of the authorization. Also, please be aware that once we disclose this information per your instructions the information is subject to re-disclosure and may no longer be protected by the HIPAA of 1996.
Date

Month Day Year
Date
Signature of Patient/Representative

Clear
Relationship to patient
(Ex: Self, Parent, Spouse, other)
DISCLOSURES REQUIRING SPECIAL CONSENT:

My signature below specifically authorizes the release of healthcare information relating to the testing, diagnosis, or treatment for:
HIV/Aids Virus
(Yes, No, or N/A)
Sexually Transmitted Diseases
(Yes, No, or N/A)
Mental Health/Psychiatric Disorders
(Yes, No, or N/A)
My signature below specifically authorizes the release of healthcare information relating to the testing, diagnosis or treatment for: Sexually Transmitted Diseases HIV/Aids Virus Drug/Alcohol Abuse Treatment Mental Health/Psychiatric Disorders
Drug/Alcohol Abuse Treatment
(Yes, No, or N/A)
Date *

Month Day Year
Date
Signature of Patient/Representative

Clear
Relationship to patient
(Ex: Self, Parent, Spouse, Other)
Date Received

Month Day Year
Date
Date Released

Month Day Year
Date
Person Sending Records
Should be Empty: