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Alabama Medical Records Release Form

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This form is provided by Montgomery Cardiovascular Associates, P.C. to authorize the disclosure or release of one person's protected health information.

Alabama Medical Records Release Form
Alabama Medical Records Release Form
MEDICAL RECORDS RELEASE FORM
To:
Physician Name: __________________ Pt Name: ___________________DOB________
Fax #:___________________________ Pt. MCA Acct #:____________________
Portions of Record Needed-----Check Applicable Sections
Discharge Summary FAX REQUESTED RECORDS TO 334-280-1600
History & Physical ATTN: MEDICAL RECORDS
Operative Rpt
ER Record
Stress Test Rpt
Chest X-Ray
Echo Report
EKG/Stress Strips
Holter/Event Monitor
Lab Work
Physician’s Progress Notes
Physician’s Orders
Other:_______________ Treatment Dates requested: _________________
InformationaboutyouisprotectedunderfederallawandyouhavetherighttorevokethisAuthorization
excepttotheextentthatwehavetakenactioninrelianceonyourAuthorization.PleasecontacttheMCA
MedicalRecordsDepartmentforan“AuthorizationRevocation”formifoneisneeded.Bysigningbelow,
you
recognizethattheprotectedhealthinformationusedordisclosedpursuanttothisAuthorizationmay
besubjecttoredisclosurebytherecipientandmaynolongerbeprotectedunderfederallaw.
Expiration:Unlessotherwise,revoked,thisauthorizationwillexpireonthefollowingdate,event,orcondition:IfIdonot
specifyanexpirationdate,event,orcondition,thisauthorizationwillnotexpire.Date:____/____/_____
Patient’sSignature:____________________________________Date:____/____/_____
AsaPersonalRepresentative,IhaveauthoritytoactfortheindividualbecauseIam:______________________
Witnessedby:_________________________________________Date:____/____/_____
FORMCAUSEONLY:
RELEASEHASALREADYBEENFAXEDTOPHYSICIANLISTEDABOVE
RELEASENEEDSTOBEFAXEDTOPHYSICIANLISTEDABOVE
RELEASENEEDSTOBESCANNEDTOPTCHART
273 Winton M Blount Loop P. O. Box 241587 Montgomery, Alabama 36124-2398
Phone (334) 280-1500 Fax (334) 280-1600
www.mcva.com
MONTGOMERY CARDIOVASCULAR ASSOCIATES, P.C .
H Forrest Flemming, MD R Eric Crum, MD Tamjeed Arshad, MD
David N George, MD Beverly A Stoudemire-Howlett, MD Iliana Arellano, MD
Paul B Moore, MD Darryl A Hamilton, MD M Todd Miller, MD
Wynne Crawford, MD Jose L Escobar, MD
Alabama Medical Records Release Form