Authorization to Disclose Health Informa

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Authorization to Release Information

I am requesting to receive a copy of my own records

I am requesting that a copy of my records to be sent to another person or entity

Name of patient requesting disclosure of medical records (Required)

Email address of patient requesting disclosure of medical records (Required)

Patient Date of Birth (Required)

Last 4 digits of SSN(Required)

Address of the organization/person you would like records sent

Information to be disclosed in release of records (please check all that apply) (Required)

Presence in treatment

Progress in treatment

Psychiatric history and assessment

Psychological assessment

Results of physical exam

Medical history/current status

Biopsychosocial assessment

Laboratory test results

Employment information

Legal status

Family information

Aftercare recommendations

Discharge summary

Financial

Other (please specify in notes)

Purpose for the disclosure of medical records (please check all that apply) (Required)

Treatment/Continuing medical care

Personal use

Billing or claims

Insurance

Legal purposes

Disability determination

School

Employment

Other (please specify in notes)

I am requesting records for: (Required)

Check here to indicate your understanding that your medical records to be disclosed under this consent may include information concerning your psychiatric, psychological, drug and alcohol abuse, HIV/Acquired Immune Deficiency Syndrome (AIDS} and/or related conditions.

Check here to indicate that you have read and agree to the terms of this Authorization.View Additional Information

Check here to indicate that you have read and agree to the terms of this Patient Request to Access Medical Records form on the date that you click “Submit” below.View terms of use

Thanks for submitting!

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