breakthroughmed.com - Authorization of Release of Medical Records

AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS
Breakthrough Medicine - 702 S Main St, Cottonwood AZ 86326 - P: 928-649-0269 | F: 866-644-6363
Patient Legal Name
Date of Birth

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState

Zip Code
Phone #
Please enter a valid phone number.
I hereby authorize release of my medical records

TO orFROM:
(current physician’s name and contact information)
to disclose protected health information of the person listed above, to:

Breakthrough Medicine - FAX (866) 644- 6363
Type of access requested (copies of the records):

Entire recordNursing notesER recordsImaging/radiologyHistory and physicalConsult reportsOperative reportsRehabilitation servicesImmunizationsLaboratory reportsCardiac studiesDemographicsProgress notesPhysician’s ordersMedication recordsOther
1. I acknowledge, and herby consent to such, that the released information may contain alcohol, drug abuse, psychiatric, HIV results or AIDS information.
2. I understand that this authorization may be revoked by me at any time except to the extent that action has been taken in reliance upon it.
3. The information used or disclosed pursuant to the authorization may be subject to redisclosure by the recipient and no longer protected.
4. I understand that there may be a fee involved with the fulfillment of this request.
5. I understand that the term, entire record, regarding release of protected Health Information means that only records generated by the named facility will be released.
6. I have read the above and authorize the disclosure of the protected health information.
Signature of Patient/Parent/Legal Guardian

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Date

MonthDayYear
Date
Should be Empty:

AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS