SOA-FORM-0003-R08-22

Medical Records Request

AUTHORIZATION FOR THE USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION HIPAA COMPLIANT AUTHORIZATION FOR RELEASE OF INFORMATION (42 CFR §164.508)
Date of Request*

MonthDayYear
Auto-Completed.
Date of Birth*

MonthDayYear
Enter patient's date of birth.
Name*

Enter patient's first name.Enter patient's last name.
Social Security Number*
Enter the last 4 digits of the patient's Social Security Number.
Email
Enter patient's e-mail address.
Other Name(s) Used:
Information Requested: I consent and authorize SurgOne, P.C. to disclose all Protected Health Information in any form (including oral, written or electronic) to:
Company | Person*
Enter Company Name.
Address*

Enter Street Address.

Enter Apartment | Suite | Unit.

Enter City.Select State.

Enter Zip Code | Postal Code.
Phone Number
Please enter a valid company phone number.
Fax Number
Please enter a valid company fax number.
Additionally, I authorize SurgOne, P.C. to disclose the PHI via mail or facsimile. I expressly request that SurgOne, P.C. disclose full and complete PHI from the time period of
Start Date*

MonthDayYear
Enter start date of medical records you would like sent.
End Date*

MonthDayYear
Enter the end date of the medical records you would like sent.
- All medical records, including, but not limited to: inpatient, outpatient & emergency room treatment; all clinical charts, reports, documents, correspondence, test results, subjective and objective complaints, statements, questionnaires/histories, office and doctor’s handwritten notes; and records received from other physicians or healthcare providers;
- All autopsy, laboratory, histology, cystology, pathology, radiology, CT Scan, MRI, echocardiogram & cardiac catheterization reports;
- All radiology films; mammograms; myelograms; photographs, CT scans; bone scans, pathology, cytology, histology, autopsy, immuno-histo-chemistry specimens; cardiac catheterization videos; and echocardiogram videos;
- All prescription and pharmaceutical records, including, but not limited to: NDC numbers and drug information handouts/monographs;
- All correspondence to/from/about me, memos, office notes, narrative summaries, and telephone messages;
- All billing records, including, but not limited to: all statements, invoices, itemized bills, and insurance records;
- All documents related to the amendment of any record requested.
I request the information be disclosed in the following format. (If blank, format and method of disclosure will be determined by SurgOne, P.C.)
Enter the format you wish to have SurgOne, P.C. to send (PDF | Fax | ETC.)
Purpose of Release*
Enter the purpose for this records release.
Authorization Effective Until:*

1 Year from Date of this AuthorizationDateOther Event Occurs
Authorization Effective Until:

MonthDayYear
Enter authorization effective until date
Other Event Occurrance:
Enter event occurance to revoke this authorization

I understand that this authorization may be revoked at any time, except to the extent already acted upon, by giving written notice to Requestor at the address listed above. I understand that treatment, payment, enrollment or eligibility for benefits may not be conditioned upon signing this authorization. I understand that the Requestor may redisclose this information, and if re-disclosed, the information would no longer be protected by federal privacy rules and regulations. Any facsimile or copy of this authorization authorizes the release of the records requested herein.*

NoYes
In addition to the authorization provisions above, I authorize the release and re-disclosure of all information, data, notes, records, reports, and all other documents to the Requestor, its consultants, experts, agents and/or other counsel relating to:

Substance Abuse (Alcohol Drug)Mental Health (Including Psychological Testing)HIV-Related Information (Including AIDS Testing)Genetic Information
THIS FORM DOES NOT AUTHORIZE RE-DISCLOSURE OF MEDICAL INFORMATION BEYOND THE LIMITS OF THIS CONSENT. WHERE ALCOHOL AND OR DRUG ABUSE INFORMATION HAS BEEN DISCLOSED THROUGH RECORDS THAT ARE PROTECTED BY FEDERAL LAW, OR MENTAL HEALTH RECORDS PROTECTED BY STATE LAW, FURTHER DISCLOSURE IS PROHIBITED WITHOUT SPECIFIC WRITTEN CONSENT OF THE INDIVIDUAL OR AS OTHERWISE PERMITTED BY SUCH LAW AND OR REGULATIONS. A GENERAL AUTHORIZATION IS NOT SUFFICIENT FOR THESE PURPOSES.
Who is completing this Medical Records Request?*

PatientLegal Guardian
Name

First NameLast Name
Patient Signature*

Clear
Legal Guarding Signature*

Clear
Should be Empty:

Medical Records Request