Authorization for the Release of Patient Medical Records Form

Dr. Aaron Rickelman, Dr. Abbi Rickelman, Dr. Brady Dougherty

1360 NW 18th Street, Suite 101, Ankeny IA 50023

Phone: 515.957.4042 Fax: 515.598.7855

Authorization for the Release of Paitent Medical Records Form
Patient Name*
Maiden Name*
If you don't have one, type N/A
Date of Birth*

MonthDayYear
I hereby request and authorize Designed 2 Move Spine & Sport, 1360 NW 18th Street, Suite 101, Ankeny, IA 50023 to:*

Disclose Information To:Receive Information From:
Provider Name*
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Information to be disclosed includes copies of:*

Daily Chart NotesProgress NotesImaging ReportsPhysical Exam FormsImaging StudiesOther
This authorization will be effective for six months after the date signed, unless cancelled in writing. I understand that the cancellation will have no effect on information release prior to receiving the cancellation. A copy of this authorization is as valid as the original.

If signing for a minor patient, I hereby state that my parental rights have not been revoked by a court of law.

Notice to recipient of information:
This information has been disclosed to you from confidential records, which are protected by law. Unless you have further authorization, laws may prohibit you from making any further disclosures of this information without the specific written consent of the patient or legal representative.

Please indicate acknowledgement by clicking "Yes" below.

Yes
Signature of Patient or Representative*

Clear
Print Signature*
Today's Date*

MonthDayYear
Should be Empty: