Authorization for Records Release
I hereby authorize NORTHWOOD OBSTETRICS & GYNECOLOGY, P.C. to perform the following actions:
I hereby authorize NORTHWOOD OBSTETRICS & GYNECOLOGY, P.C. to perform the following actions:
Receive records from a previous medical provider
Send records to another medical provider
What is the name of the office or provider that we are sending or receiving records from?
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What is their address?
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What is their phone number?
Please enter a valid phone number.
What is their fax number?
*
Please enter a valid phone number.
What records do you authorize? (Check all that apply)
Most recent history & physical exam
Labs, ultrasounds, x-rays and other imaging
Operative Reports
Discharge Summary
All of the above
Dates of interest - From:
date
To:
date
Please indicate the purpose for disclosing this information:
Moving to/from area
Attorney request
Insurance or disability issue
Changing health care provider within our area
I hereby authorize and request the release of all my pertinent medical records, which may include: Communicable disease and infection information, as defined by statute and Michigan Dept. of Public Health Rule. This pertain to information regarding such conditions as venereal diseases, Tuberculosis, Hepatitis B, HIV and AIDS. Alcohol and/or drug abuse treatment information. Mental Health treatment records, psychological services and social services information, including communications made to me by a social worker or psychologist. My signature indicates agreement with the statement above:
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Clear
Patient's Full Name:
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First Name
Middle Name
Last Name
Today's Date:
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Month
-
Day
Year
Date
Name of Guardian or Responsible Party (If applicable)
First Name
Last Name
Submit
Should be Empty: