Health Brigade - Release of Information

Release of Information

1010 N. Thompson Street, Richmond VA 23230

Phone: (804) 358-6343
Please Select Clinic Fax*

Medical Clinic FAX: (804) 864-2586Mental Health Clinic FAX: (804) 354-9124
CONSENT TO RELEASE OR OBTAIN CONFIDENTIAL HEALTH CARE INFORMATION
Patient's Information:
Legal Full Name*
Date of Birth*
Street Address*

Street

Street Address Line 2

City, State, ZIP CodeState / Province

Postal / Zip Code
Phone*
Email Address*
Please Select One*

Obtain FromRelease To
Clinic Contact Information:
Name*
Street Address*

Street

Street Address Line 2

City, State, ZIP CodeState / Province

Postal / Zip Code
Fax (for Continuity of Care only)
I, {legalFull}, hereby authorize Health Brigade to release or to obtain the health information indicated below that is contained in my patient record. I understand and acknowledge that this may include physical and mental illness, alcohol/drug abuse, genetics and/or HIV/AIDS test results or diagnoses.

INDICATE APPROXIMATE DATE(S) OF SERVICE:
Date(s) of Service
INFORMATION TO BE RELEASED OR OBTAINED*

AllBone DensityCardiac Studies/EKGsClinic & Progress NotesDischarge SummariesER VisitsHistory and PhysicalHospital NotesImmunization RecordsLaboratory ReportsMammograms/Breast ImagingMental Health RecordsOperative ReportsRadiology ReportsRadiology ImagesPap/Colposcopy ReportsPathology/Biopsy ReportsPsychotherapy NotesOther
I understand that I have the right to take back this authorization, at any time, except when the release of records has already happened. I must submit this request in writing to the person who has my records. My removal of permission will not be effective until delivered in writing to the person who has my records. Information disclosed to someone who has received my records based on my permission can be re-disclosed by them and is no longer protected by federal privacy regulations. I understand that my health care and the payment for my health care will not be affected if I do not sign this form.

This permission will end 12 months from the date of signature unless I write an earlier date here:
Date

MonthDayYear
ATTENTION: This is a legal document. Please read carefully. By signing, you agree that you understand and accept.
Patient Signature*

Clear
Date *

MonthDayYear
Date
Printed Patient Name

First NameLast Name
Should be Empty: