REQUEST MEDICAL RECORDS

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573-248-1010

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REQUEST MEDICAL RECORDS

REQUEST MEDICAL RECORDS

Request Medical Records

First Name:

Last Name:

Date of Birth

Phone:

Email:

Street Address

City

State

Zip

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

YES

NO

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

Consultation Notes

Operative Reports

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

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):

What form of records

Medical Information only

Financial Information only

Medical and Financial Information

Verbal only

Written only

Verbal and Written

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

Sel

Family Member

Other

If other than self: First Name

Last Name

Phone

Street Address

City

State

ZIP

How should records be delivered?

Mailed

Faxed

Picked up

Fax Number:

Records needed by Date:

Date to be picked up

Date Processed by

Other Details to Share as we gather records:

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

This authorization will expire (insert date or event):

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.

YES

NO

If I fail to specify an expiration date/event, this authorization will expire 1 year from the date it was signed.

YES

NO

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

YES

NO

Free Text

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

First Name (must be 18 or older)

Last Name (must be 18 or older)

Date Submitting Form

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We will get back to you as soon as possible.

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HOME
OUR TEAM
OUR SERVICES
WORKERS COMPENSATION
CONTACT US
FOR PATIENTS

We care for patients of all ages who share one goal—getting back to life quickly and safely. At Midwest Orthopedic Specialists, our fully patient-focused team is highly trained, and dedicated to your comfort.

CONTACT US

Phone: (573) 248-1010

Fax: (573) 231-0046

Monday-Friday

8:00am – 5:00pm

COME SEE US

188 Medical Drive

Hannibal, MO 63401

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