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Section I: Patient Information

Patient First Name

Patient Last Name

Date of Birth

Social Security Number

Patient Phone

Address

City

State Select a StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

Zip Code

Section II: Provider of Medical Information

First Name

Last Name

Phone

Organization

Address

City

State Select a StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

Zip Code

Section III: Information Requested

Records to be Released:

History & Physical Evaluation

EKG Reports

Discharge Summary

Operative Report

X-Ray Reports/Ultrasound Reports

Pathology Report

Laboratory Reports

Other:

Dates of Treatment

Purpose of Disclosure

Section IV: Recipient of Information

First Name

Last Name

Organization

Phone

Fax

Address

City

State Select a StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

Zip Code

Pursuant to the HIPAA Privacy Rules, the patient or his/her authorized representative acknowledges that he/she:

1. Has the right to revoke this authorization in writing to the extent that a covered entity has not already relied upon the patient’s consent to use or disclose protected health information. This authorization shall remain in force until it is revoked please (check box) below to agree or (list date) below, whichever occurs first.

(check box)

(list date)

2. Understands that the health information used or disclosed following this authorization may be subject to re-disclosure by the recipient and may no longer be protected by the HIPAA Privacy Rules

Name of Patient

Name of Authorized Representative

By submitting this request, I am acknowledging that it is being requested by the patient stated above.