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This form is provided by Front Range Orthopedics to authorize the disclosure or release of one person's protected health information.
Medical Records Release Form
I hereby authorize the use or disclosure of health information from the medical record of:
Patient Name ______________________________________________________________
Date of Birth _____/_____/_____ Best Contact telephone #_____________________
I authorize FROC, P.C. to release confidential health information about me, by releasing a
copy of my medical records, a summary or narrative of my protected health information, or
verbally to the individual or organization listed below.
Specific Description of the Information to be released:
__ Progress Notes__ Radiology films
__ Other________________________ Diagnostic study reports (labs, radiology, etc.)
_____________________________ Outside records (hospital, therapy, other doctors)
I understand that the information in my health record may include information relating to
sexually transmitted disease, acquired immunodeficiency syndromes (AIDS), or human
immunodeficiency virus (HIV). It may also include information about behavioral or mental
health services, and treatment for alcohol and drug abuse.
__ Yes, I consent to the release of this information.
__ No, I do not consent to the release of this information.
This information may be disclosed to and used by the following individual or