AUTHORIZATION RELEASE OF MEDICAL RECORDS …
AUTHORIZATION RELEASE OF MEDICAL RECORDS (PROTECTED HEALTH INFO)
I,_______________________________________________________________________________, hereby
authorize the release of my medical records dated: __/__/20__ to __/__/ 20__ .
Picked up by _________________________________ (Photo ID Required)
Mailed to:
Self, Physician, Hospital Name, etc¡
Phone
Address
City
State
Zip
Fax: We will only fax records to a health care provider (Hospital, insurance company, or doctors office)
Company / Name
Phone
Fax
I UNDERSTAND THAT THE SPECIFIC REPORTS DISCLOSED SHALL INCLUDE:
All records
Records specific to: __________________________________________
Please specify: R/L, leg, arm, wrist, shoulder, back, etc¡
THE SPACES BELOW GIVE SPECIAL AUTHORIZATION FOR THE RELEASE OF SUPER CONFIDENTIAL INFORMATION
REGARDING ALCOHOLISM AND/OR DRUG ABUSE, HIV (AIDS) TESTING, AND/OR TESTING FOR SEXUALLY TRANSMITTED
DISEASES
*INITIAL EACH LINE THAT APPLIES*
__________
Medical information regarding alcoholism and/or drug abuse (if applicable) may be
Released to the recipient noted above.
__________
Medical information regarding HIV (AIDS) testing and/or testing for sexually
Transmitted diseases (if applicable) may be released to the recipient above.
_____________
Medical information regarding psychiatric care/or counseling (if applicable) may
be released to the recipient above.
I Understand:
1.
2.
3.
4.
This consent is revocable by me, in writing any time except after the action has taken place.
This consent will expire either in one year after the date of signature or automatically when the records
requested on this form have been mailed to the above requested.
The medical records provided in response to this request are subject to further distribution in relation
to workplace injury if applicable.
That I may refuse to sign this authorization.
Date:_________________Signed:____________________________________SS#/DOB________________________
PATIENT
ID Verified: _____
FHCC-440
REV 11/2015
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