Authorization for Release of Medical Records - TeamHMH
Occupational Health Surveillance Team 2441 Highway 33, Suite B Neptune, NJ 07753
p. 732-897-7797 f. 732-897-7796
AUTHORIZATION FOR THE RELEASE OF MEDICAL RECORDS
*PLEASE PRINT*
I authorize Hackensack Meridian Health Services to release information contained in the medical records of:
NAME: _____________________________ (______________) DATE OF BIRTH:______/_______/______
(maiden)
ADDRESS: ____________________________________________________________________________
(street)
(city, state & zip code)
(Daytime) Phone: _____________________________
Pertaining to: ___ INFLUENZA The records pertain to my CURRENT employment with:
RMC PLEASE:
JSUMC
OMC
BAYSHORE
SOMC
SRI
Other:__________________________________
____ MAIL MY RECORDS TO THE ABOVE ADDRESS ____ FAX MY RECORDS TO__________________________________________________ ____EMAIL________________________________________________________________
SIGNATURE_____________________________________ DATE ____/_____/_____
Please note that it may take up to 30 days to receive and process any request for medical records. Additionally, any missing information will cause a delay in
the copying of your medical record.
For Meridian Employees, please make a copy of your record before forwarding to a third party. The Occupational Health Department will provide the first copy of your employee health record to you free of charge. Additional requests will be charged a $10.00 retrieval fee and a $1.00 per page charge.
FOR OFFICE USE ONLY
Date request received ____/____/____ Date completed ____/____/____ Completed by______________
................
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