Medical Record Release

Authorization For Release Of Medical Records

Patient Name*
Email*
DOB*
Treating Physician at Southwest Ob Gyn*
Purpose of Release*
- Changing Physicians
- PCP
- Specialist
- Personal
Specific Records Requested*
- Office Notes
- Laboratory Reports
- Radiology Reports
Other Records
Release Records To:
From Date of Service*
To Date of Service*
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 State ZIP Code
Phone Number*
Fax Number
I consent to the release of any information regarding HIV, AIDS, sexually transmitted infections, drug or alcohol use, psychiatric and mental health conditions.
Initial*
Date*
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*
Relationship to Patient*
Comments
This field is for validation purposes and should be left unchanged.