Southwest Ob/Gyn

Medical Record Release

Authorization For Release Of Medical Records

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  • Release Records To:

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  • I consent to the release of any information regarding HIV, AIDS, sexually transmitted infections, drug or alcohol use, psychiatric and mental health conditions.

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  • Medical Record fees: no more than $25 for the first 20 pages and $0.50 for each copied page thereafter. Records printed to disks are $5.00. Completion of affidavits is $15.00. A reasonable fee for actual costs for mailing, shipping or delivery of records may also be charged. Southwest Ob Gyn will furnish records within 15 business days after the date of receipt of the request. Payment in full is required prior to records being released.
  • I understand that this authorization will remain in effect unless revoked by me in writing. I hereby release the facility, its employees and officers, appointed representatives and attending physicians from legal responsibility or liability for the release of the above information to the extent indicated and authorized herein or if the party to whom PHI is released, releases to another entity.
  • Date Format: MM slash DD slash YYYY
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