Medical Record Release Request Form

 

click here to retrieve form

Instructions for Completing


SECTION A: INFORMATION TO BE USED AND/OR USED AND TO WHOM

   1. If desired, enter a date for which the authorization should be valid through.
   2. Print the CURRENT name of the Patient, then all other names patient known by
   3. Enter the LAST FOUR DIGITS of Social Security Number AND Date of Birth of the Patient
   4. Print the name of the person(s) or organization(s) authorized to RELEASE the information
   5. Print the name of the person(s) or organization(s) authorized to RECEIVE the information
   6. Mark any information to be used or disclosed (X)
   7. Print a description of the purpose of the requested use and/or disclosure

SECTIONS B, C, D: READ CAREFULLY

SECTION E: SIGNATURE

   1. Signature of Person Requesting the Release of Information
        a. Must be the patient unless the legal Power of Attorney (POA) or patient is a minor. Proof of POA is required
   2. Printed name of Person Requesting the Release of Information
   3. Print the Relationship to the Patient
   4. Today’s Date
   5. Signature of a Witness
   6. Printed name of a Witness
   7. Today’s Date

If an entire chart for a Date of Service (DOS) is requested, we standardly release:
  • Discharge Summary
  • History & Physical
  • Physician Progress Notes
  •  Emergency Room Record
  • Patient Registration
  • Respiratory Therapy
  • Substance Abuse
  • Labs
  • EKG
  • Echo
  • Pathology
  • Consultation
  • Radiology
  • Physical Therapy
  • Speech Therapy
  • Physician Orders
  • Operative Report
  • Occupational Therapy
  • Psychosocial History

The records will be provided within 30 days of request if the visit was from 2011-2013. Other records could possibly require 60 days. The records MUST be picked up by the patient, parent or legal POA. The person requesting the records MUST bring the completed and signed request along with a government issued picture ID to the medical records department for verification and processing Mon.- Fri. 8:30 AM – 4:30 PM.