Release of Information

Release of Information
PATIENT INFORMATION:
Patient's Name *

First Name Last Name
DOB *

Month Day Year
Date
Address *

Street Address

Street Address Line 2

City State

Zip Code
Phone *
Please enter a valid phone number.
REQUESTS RECORDS FROM (WHO HAS YOUR RECORDS NOW):
I hereby authorize:
Medical Facility *
Address *

Street Address

Street Address Line 2

City State

Zip Code
Phone *
Please enter a valid phone number.
Fax
TO RELEASE INFORMATION TO (WHO YOU WANT TO RECEIVE YOUR RECORDS):
Name (Person or entity) *
Address *

Street Address

Street Address Line 2

City State

Zip Code
Phone *
Please enter a valid phone number.
Fax
INFORMATION TO BE RELEASED:
My medical records for the dates: *

Month Day Year
Date
to: *

Month Day Year
Date
Select all that apply:

Complete Record Office Notes Lab tests Operative/Procedure Reports Imaging Reports
I understand that the information to be disclosed may include information regarding the following conditions: *

Alcoholism, drug and/or alcohol abuse (Protected by State/Federal Law) AIDS (Protected by State/Federal Law) Psychological/psychiatric conditions (Protected by State/Federal Law)
Authorization: *

I certify that I have given consent freely and voluntarily. I understand that I may revoke this authorization, in writing, at any time unless action based on it has already taken place. Redisclosure of medical my information by those authorized to receive the above Specified information should not be made without my further written consent. I agree Peak Gastroenterology Associates, PC is not responsible for the misuse and Cannot guarantee the confidentiality of medical information once it has been released to another party. I hereby release Peak Gastroenterology Associates, PC from any liability which may result from furnishing the information requested as authorized in this release. I acknowledged that seven to ten working days will be allowed for information to be released. I understand that a fee may be charged for copies of medical records. I agree that a photocopy of this release shall be valid as the original.
This consent is in effect until: *
(Ex: 1 year from request date)
Date *

Month Day Year
Date
Signature of Client or Personal Representative *

Clear
If I am unable to personally pick up my records from Peak Gastroenterology Associates PC, I authorize:
Name

First Name Last Name
Relationship
Sender
Should be Empty:

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Release of Information

PATIENT INFORMATION:

REQUESTS RECORDS FROM (WHO HAS YOUR RECORDS NOW):

TO RELEASE INFORMATION TO (WHO YOU WANT TO RECEIVE YOUR RECORDS):

INFORMATION TO BE RELEASED: