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Generic Authorization to Release Medical Records Form


Generic Authorization to Release Medical Records Form
Generic Authorization to Release Medical Records Form
Denton Heart Group
Authorization to Release Medical Records
Name of Patient ________________________________ Date(s) of Service ____________________
Date of Birth ___________________ Social Security Number _______________________
I, the undersigned, authorize the release of, or request access to the information specified below from the
medical record(s) of the above name patient.
PATIENT INFORMATION IS NEEDED FOR:
Continuing Medical Care Military Social Security/Disability
Insurance Personal Use Other: _______________
Legal Purposes School _____________________
INFORMATION TO BE RELEASED OR ACCESSED:
History & Physical Consultation Report Emergency Room Record
Operative Reports Discharge/Death Summary Face Sheet
Lab/Path Reports X-Ray Reports/Images Other: ________________
The above information may be released (specify name or title of the individual or the name of the organization to which
records are to be released and the appropriate address):
TO:
________________________________________________________________________________________________
(Doctor, Hospital, Attorney, Insurance Company, Self, etc.) Phone Number
________________________________________________________________________________________________
Address (Street, City, State and ZIP)
FROM:
________________________________________________________________________________________________
(Doctor, Hospital, Attorney, Insurance Company, Self, etc.) Phone Number
________________________________________________________________________________________________
Address (Street, City, State and ZIP)
I understand that my records are confidential and cannot be disclosed without my written authorization, except when
otherwise permitted by law. Information used or disclosed pursuant to this authorization may be subject to re-
disclosure by the recipient and no longer protected. I understand that the specified information to be released may
include but is not limited to history, diagnoses, and/or treatment of drug or alcohol abuse, mental illness, or
communicable disease, including HIV and AIDS.
I understand that I may revoke this authorization in writing at any time except to the extent that action has been taken in
reliance upon the authorization.
The authorization will expire six (6) months from the date of my signature, unless I revoke the authorization prior to
that time.
Date: __________________ Signature: _______________________________________________
Patient or Legally Authorized Representative
_______________________________________________
Printed Name of Patient or Legally Authorized Representative
____________________________________________________
Relationship to Patient
Generic Authorization to Release Medical Records Form