Elige tu idioma encima
Choose your language above

I understand I may change or revoke this authorization at any time by providing written notice to Variety Care at: Variety Care, Attn: Medical Records, 6800 Broadway Extension, Oklahoma City, OK 73116. I understand I cannot restrict information that may have already been shared based on this authorization by a revocation or change.

By signing this request, the patient or representative acknowledges the following:

• I understand I have free access to my records via the Patient Portal and chose to request records via above stated method.

• I understand that if I provide a phone, fax or email and request that my records be released by that medium that those means of communication are not always secure and Variety Care cannot guarantee the confidentiality of my information when transmitted by those means. I understand that if I do not make a selection, that Variety Care will release my records as paper records through the mail.

• I understand that there are fees associated with the release of Medical Records from Variety Care and that I am responsible for paying those fees in accordance with the law. Variety Care may impose a fee of $0.50 for each page to cover the cost of labor and copying, plus postage for the requested information. $0.30 for each page in digital copy.

• I understand that Variety Care has up to thirty (30) days from receipt of my request to process my request and confirm that it is appropriate for the release of records.

• I understand that I may request my records in format other than paper (electronically or on CD) by providing that preference to Variety Care. Variety Care will produce my records in the format I request if it is possible. If I do not make a request for a specific alternative format, Variety Care will release my records as paper records.
  
  
• I understand that this release may contain records that may indicate the presence of a communicable/non-communicable or venereal disease, which may include but is not limited to diseases such as Hepatitis, Syphilis, Gonorrhea, Human Papilloma Virus (HPV), Chlamydia, Herpes Simplex Virus, or the Human Immunodeficiency Virus (HIV), also known as Acquired Immunodeficiency Syndrome (AIDS).
  
  
• I understand that if I have requested all of my records or my behavioral health records be released, that the information included in that release may contain information relating to my treatment for psychological, psychiatric, alcohol or substance abuse conditions.
  
  • I understand that if the patient is a minor, release of any information regard alcohol/substance abuse treatment requires
    their direct permission and they must sign this form under 42 C.F.R §2.14 even if I am their parent or guardian.

• I understand that Variety Care is not responsible for the protection of my information that has been released under this request. I specifically release Variety Care and its agents and employees from any liability for release of information connected with this request. I understand that my information may no longer be protected when it is released.
  
  
• I understand that I may inspect or obtain a copy of the protected health information shared under this authorization by sending written request to the address listed.
• I understand that I may request a copy of this request for records from Variety Care but will not be given a copy unless I request it.
  
  
• Unless the purpose of this authorization is to determine payment of a claim for benefits, the requesting entity will not condition the provision of treatment or payment for my care on my signing this authorization.
  
  
• I am making this request voluntarily. I understand that my treatment will not be impacted whether I sign this request or not.

If you are not the Patient but you are signing on behalf of a patient, please complete this section:

You MUST attach proof of your authority to act on behalf of the patient as checked above (other than parent).