Midwest Orthopedic Specialists » Request for Release of Records

Name *

First

Last

Date of Birth *

Address *

SSN *

Authorization *

I authorize the use or disclosure of the above named individual’s health information as described below.

The following individual /organization is authorized to make the disclosure (organization to release the records):

The type of information to be used or disclosed is as follows (request only the information you want released)

All medical records from your facility.
Consult Notes
Operative reports

Only records from (DATE to DATE)

Testing and/or lab results (describe the dates or type of tests you would like disclosed):

X-rays and/or other imaging films (please describe the dates or types of x-ray or images you would like disclosed):

Other (please describe):

Other types of information to be used or disclosed (Other)

Medical Information only
Financial Information only
Medical and Financial Information
Verbal only
Written only
Verbal and Written

The information identified above may be used by or disclosed to the following individual/organization:

(To whom are the records being released. — If family, list name and relationship)

Name

Phone

Address

Fax

To be

Mailed
Faxed
Picked Up

Records needed by date

Date to be picked up

Processed by date

The information will be used for the following purpose (check as many as applicable):

My personal records
Disability Claim
Social Service Agency
Second opinion (as recommended by my physician)
Referred to specialist
Attorney
Insurance Company
Relocation of self of family
Second opinion (as preferred by patient)
Transfer of care

Other

This authorization will expire (insert date or event):

Agreements *

I understand that I have a right to revoke this authorization at any time. I understand that if I revoke this authorization, I must do so in writing and present my written revocation to the Medical Records department. I understand that the revocation will not apply to information that has already been released in response to this authorization. I understand that the revocation will not apply to my insurance company when the law provides my insurer with the right to contest a claim under my policy.
If I fail to specify an expiration date/event, this authorization will expire 1 year from the date it was signed.
I understand that the information in my health record may include information relating to sexually transmitted disease, acquired immunodeficiency syndrome(AIDS), or human immunodeficiency virus(HIV). It may also include information about behavioral or mental health services, and treatment for alcohol and Abuse. 8-18-42 308- 625.3

I understand authorizing the use or disclosure of the information identified above is voluntary. I need not sign this form to ensure healthcare treatment.

Name (must be 18 or older) *

First

Last

Date *

Request for Release of Records

AUTHORIZATION TO USE OR DISCLOSE HEALTH INFORMATION