Medical Record Release & Disclosure

Southeastern Medical Center

Medical Record Release & Disclosure
Patient Name*

First NameLast Name
Social Security Number*
Date of Birth*

MonthDayYear
Phone Number*
Please enter a valid phone number.
Mailing Address*

Street Address

Street Address Line 2

CityState

Zip Code
Are you the patient completing this form?*
The undersigned hereby authorizes Guernsey Health Systems to release the following information, and consents to disclosure of any and all confidential information contained therein, from paper or electronic medical records maintained by said facility to:
Parent / Legal Guardian of the patient?

Parent / Legal Guardian of the patientLegal Power of Attorney for patientOther
Name of person, facility, or organization:
Please select how you would like to receive this request:
Fax Number to send to:
Please enter a valid phone number.
Email to send to:
example@gmail.com
Mailing Address to send to:

Street Address

Street Address Line 2

CityState

Zip Code
Information Authorized for Release:
Hospitalization / Treatment Date:*

MonthDayYear
Date
Information Released:*
Purpose of Disclosure (check which applies):*

Medical CarePersonal InformationInsuranceLegalOther
Note: All Medical Records selected to be disclosed via email will be sent encrypted.
Completed By:

First NameLast Name
Completed Date

MonthDayYear
Date
Please verify that you are human*
Should be Empty:

Southeastern Medical Center