Release Consent Form

Consent for Release of Confidential Medical Records
Patient Name*
Date of Birth*

MonthDayYear
Date
Purpose / Need for Information:*

Changing PhysiciansPersonal UseNo longer a patient and need a copy of my recordsMovingOther
Specific Documents Requested:*

Medical Records (Visit notes)Laboratory ReportsRadiology ReportsImaging ReportsOther
How would you want your records provided? (Choose one option):*

Paper copy of my records (Cost to be determined; .25 cents per page)USB with my records (Cost: $8.71)Please send via email. (I authorize for these documents to be sent via an unsecure email and Grace Medical Home will not be responsible if my information is compromised)Fax my records to the fax number of the facility/practice indicated below
This information, including diagnosis and records of any evaluation, examination and/or treatment rendered to the above named during the period (Time frame or Dates you need records for): *
Information Requested From (Facility / Practice Name) (or Self if you are the patient):*
Facility / Practice Address:
*** Please know that not listing the facility information will delay the process of processing your records ***
Phone Number*

AREA CODEPHONE NUMBER
Fax

AREA CODEFAX NUMBER
Signature of Patient / Legal Representation*

Clear
Date*

MonthDayYear
Date
Name of person filling this form out*
This request is authorized to include any Federal and/or State protected information under Florida Statutes 394.459(9) Psychiatric Information. 397.053/396.112 Drug and/or Alcohol Abuse Information. 381.609 HIV and Aids Related conditions and/or 397.501(3) Records of a Minor Client. I understand that this authorization will expire 12 months from the date of the signature or when acted upon, whichever event occurs first. I hereby release to the following addressee, its employees and appointed representatives from any and all liability that may arise from the release of information as I have directed. This authorization for the release of the above indicated documents may be revoked at any time, upon notification of the patient or representative as signed above. Revocation has no effect on prior action taken under direction of the signed dated consent for release.
Should be Empty:

Consent for Release of Confidential Medical Records