Medical Record Release Authorization
Patient Information
Patient Name
Maiden Name
Date of Birth
Home Phone
Cell Phone
Work Phone
Address
City
State
Zip
Email
Authorization
A. I hereby authorize records FROM:
Name
Address
City
State
Zip
Phone
Fax
B. To be released TO:
Name
Address
City
State
Zip
Phone
Fax
Purpose
C. This request is being made for the following purpose(s):
Date Range
From
To
Physicians' Office Notes
Laboratory/Pathology Reports
Other
Terms
I understand that authorizing the disclosure of this health information is voluntary. I can refuse to sign this authorization. I need not sign this form in order to assure treatment. I understand that any disclosure of information carries with it the potential for authorized redisclosure, and the information may not be protected by federal confidentiality rules. If I have questions about disclosure of my health information, I can contact the authorized individual or organization making the disclosure.
I understand that the information in my medical record may include information relating to sexually transmitted diseases, acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV). It may also include information about behavioral or mental health services and treatment for alcohol and drug abuse.
I understand that I have a right to revoke this authorization at any time. I understand that if I revoke this authorization, I must do so in writing and present my written revocation to the Medical Records Department. I understand that the revocation will not apply to information that has already been released in response to this authorization. I understand that the revocation will not apply to my insurance company when the law provides my insurer with the right to contest a claim under my policy.
I have read the information provided on this release form and do hereby acknowledge that I am familiar with and fully understand the terms and conditions of this authorization.
*Subject to Fees - see below
*PLEASE READ Fee Information: Plaza Infectious Disease, PC will provide all medical records requested from our office. We reserve the right to charge the fee schedule as set by the State of Missouri. A $26.06 handling fee, $0.60 per page, and postage may be invoiced to you with all the necessary directions to receive your records. By signing this authorization, you are agreeing to pay for your records. In the case of continuity of care, we may transfer a minimal portion of records directly to a physician as a courtesy.
This authorization will expire one (1) year from the above date unless I specify an expiration date.
Patient/Parent/Guardian or Authorized Representative Signature
(required) – Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button I understand and agree that this is a legal representation of my signature.
Date