Release of Information Form

Authorization to Release Medical Information
PATIENT INFORMATION:
Patient Name
Date of Birth

Month Day Year
Date
Phone #
Address

Address

Street Address Line 2

City State

Zip
MEDICAL INFORMATION RELEASED TO:
Individual/Organization Information Released To
Address
City, State, Zip
Phone Number
Fax #
MEDICAL INFORMATION REQUESTED FROM:
Individual/Organization Requested Information From
Address

Address

Street Address Line 2

City, State, Zip
Phone #
Fax #
PURPOSE OF THE DISCLOSURE:
Purpose of Release of Records

Personal Use Physician/Organization for Continuation of Care Legal Other
METHOD OF DELIVERY:
A printing fee of $10.00 will be charged for records more than 5 pages.

By US Mail Pick up by the Patient Email
E-mail address
example@example.com
A photo ID is required to pick up records.
Information Requested

Consultation Reports, Clinic Notes, Lab Reports Entire Medical Record Records from other providers in DBDT, LLC possession. Other
SENSITIVE MEDICAL INFORMATION TO BE RELEASED (Patient or Patient Representative Initial and Date Required for Each Item):

I understand that the records requested above may contain sensitive medical information that requires my specific consentinorderto

be released. I specifically authorize the release of the following sensitive medical information:
Release of Mental Health/ Developmental Disabilities
Initial if you would like to release Mental Health / Developmental Disabilities
Date

Month Day Year
Date
Drug/Alcohol Use
Initial if you would like to release Drug / Alcohol Use
Date

Month Day Year
Date
PLEASE READ THE FOLLOWING STATEMENTS CAREFULLY:
- I understand that this authorization is voluntary and I may refuse to sign it. The immediate consequences of my refusal will be that DBDT, LLC will not receive or release the medical information listed above through this authorization. I understand my treatment, payment, enrollment, or eligibility for benefits will not be conditioned on whether I sign this authorization.
- I understand that I may revoke this authorization, at any time, by notifying the DBDT, LLC in writing at the address listed above. I understand my written revocation is effective only when DBDT, LLC receives it. I understand that my later decision to revoke this authorization will not affect any action, use, or disclosure in reliance on this authorization, which cannot be reversed.
- I understand I have the right to inspect and/or receive a copy of the medical information listed above and also receive a copy of this authorization form.
- I understand that medical information disclosed through this authorization may no longer be protected by federal health information privacy laws. I also understand that sensitive medical information (identified above) disclosed through this authorization may require my additional authorization to be further disclosed.
- I understand this authorization will terminate ninety (90) days after my date of signature and will not be able to be disclosed beyond this date.
Signature of Patient or Patient Representative

Clear
Date/Time

Month Day Year
Date
IF Signed by Other than the Patient : Print Patient Representative's Name

First Name Last Name
Phone Number of Patient Representative
Representative's relationship with the Patient and/or the authority (e.g., Parent, Legal Guardian, Identified Health Care Surrogate, Power of Attorney,etc
Should be Empty:

PATIENT INFORMATION:

MEDICAL INFORMATION RELEASED TO:

MEDICAL INFORMATION REQUESTED FROM:

PURPOSE OF THE DISCLOSURE:

METHOD OF DELIVERY: