Nylander_Medical Records Release

AUTHORIZATION FOR DISCLOSURE OF HEALTH INFORMATION
By checking the box, I agree to the terms & conditions.*
Which doctor's records are being released?*

Michael Swan, MDBarbara Nylander, MD
If Barbara Nylander, what year was your last appointment? Year
Patient Information:
Patient's Name:*
Last, First Middle
Patient's Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
DOB:*

MonthDayYear
Date
Release records to: ALL INFORMATION MUST BE COMPLETED
Name:*
New Provider's Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Fax Number:*
Please enter a valid phone number.
Phone Number*
Please enter a valid phone number.
Information to be released: DUE TO SIZE OF CHARTS WE WILL SEND THE LAST 5 YEARS OF RECORDS*

Medical History, Exams, ReportsLaboratory ReportsHospital Records & ReportsDiagnostic Test ReportsSurgical Reports/Operative NotesConsultations Reports
I understand I have the right to:
- Receive a copy of this authorization
- Refuse to sign this authorization and that treatment, payment, enrollment in a health plan or eligibility for health care benefits may not be contingent on my signing this authorization
- Revoke this authorization, except to the extent that the person(s) and/or organization(s) listed above have already made in reference to this authorization
Records are not kept on site. We ask for 90 days to obtain your records from storage, copy and mail/fax. There will be a $30 fee for copying and transferring records. This must be paid prior to records being pulled. This can be paid by cash in the office or by credit card.
Name on card: Year
Card Number: Card Number EXP Date:EXP Date CCV: CCVSignature for Payment: Signature
Signature for Records Release:*

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AUTHORIZATION FOR DISCLOSURE OF HEALTH INFORMATION