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Microsoft Word - 24.99 KB]
Permission to get records
I, , with a date of birth, ,
(patient name) (patient's DOB)
give my permission for
(doctor's or hospital name who has records)
to give my medical records (as described on p. 2) to
so that he/she can better understand
(my doctor's name)
my condition and help me.
Permission to get sensitive information
By putting my initials by each item below, I understand that I allow records to be sent that may have information about:
my mental health,
a disease I may have that others could get from me, like HIV/AIDS,
genetic records, and/or
drug and alcohol records.
I understand that:
- I do not have to share these records.
- If I want to take away the permission for my doctor to get these records, I need to talk to my doctor or a staff person and sign a paper.
- This form is only good for 3 months from the date I sign it.
Patient's Signature Date
Authorized Representative's Signature Date
Relationship of Authorized Representative
Consent for release of medical records for
(patient name)
Date:
Requesting records from:
Name of Practice:
Name of Physician:
Fax number:
Address:
Types of records we are requesting
___ Any and all types of records you have for this patient
___ Doctor visit notes ___ Doctors orders
___ Emergency room notes ___ Nurses notes
___ Urgent care notes ___ Discharge summary
___ History and physical ___ Lab reports
___ Hospital progress notes ___ Radiology reports
___ Operation or procedure notes ___ Consultations
___ Clinic notes ___ Other
___ Pathology reports
Records within the following dates:
___ All records for this patient
___ Records dated between and
Please send records to:
Attention:
At fax number:
Or mail to:
For any questions please call (phone number): and ask for:
