Health Literacy Universal Precautions Toolkit, 2nd Edition

Release of Medical Information

[Microsoft Word file Microsoft Word version - 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:                                                                                        

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Page last reviewed February 2015
Page originally created February 2015
Internet Citation: Release of Medical Information. Content last reviewed February 2015. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/quality-patient-safety/quality-resources/tools/literacy-toolkit/healthlittoolkit2-tool11e.html