Medical Record Release Authorization For Release Of Medical Records Patient Name* Email* DOB* Date Format: MM slash DD slash YYYY Treating Physician at Southwest Ob Gyn* Purpose of Release* Changing Physicians PCP Specialist Personal Specific Records Requested* Office Notes Laboratory Reports Radiology Reports Other RecordsRelease Records To:From Date of Service* Date Format: MM slash DD slash YYYY To Date of Service* Date Format: MM slash DD slash YYYY Name of Person, Provider or Facility that records will be sent to*Please indicate if records will be Picked up Mailed Address Records to be sent to Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone Number*Fax NumberI consent to the release of any information regarding HIV, AIDS, sexually transmitted infections, drug or alcohol use, psychiatric and mental health conditions.Initial*Date* Date Format: MM slash DD slash YYYY 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.Please indicate if records are to be printed to CD Paper Signature of Patient / Guardian*Date* Date Format: MM slash DD slash YYYY Relationship to Patient*PhoneThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle Ajax powered Gravity Forms.
