Home > Life > Medical Forms > Medical Records Release Template > Maryland Medical Records Release Form > Maryland Medical Records Release Form 1

Maryland Medical Records Release Form 1

At Speedy Template, You can download Maryland Medical Records Release Form 1 . There are a few ways to find the forms or templates you need. You can choose forms in your state, use search feature to find the related forms. At the end of each page, there is "Download" button for the forms you are looking form if the forms don't display properly on the page, the Word or Excel or PDF files should give you a better reivew of the page.
This form is provided by Georgetown University Hospital to authorize the disclosure or release of one person's protected health information.

Maryland Medical Records Release Form 1
Maryland Medical Records Release Form 1
A copy of this signed authorization must be given to the individual.
v.10.19.05
General Medical Records Release and
Authorization for Use or Disclosure of Protected Health Information
Please complete the following information:
Patient Name: _______________________________________________________________
Address: _______________________________________________________________
_______________________________________________________________
Phone: _______________________________________________________________
SSN: ____________________________________Date of Birth:_____/_____/_____
I authorize the custodian of records of: or other person/entity (specifically
describe) to disclose/release the following information* (check all applicable):
All records
Laboratory/pathology records
X-ray/radiology records
Billing records
Abstract/Summary
Pharmacy/prescription records
Other (describe specifically)
*Note: If these records contain any information from previous providers or information about HIV/AIDS status, cancer diagnosis,
drug/alcohol abuse, or sexually transmitted disease, you are hereby authorizing disclosure of this information.
These records are for services provided on the following date(s):
Please send the records listed above to (use additional sheets if necessary):
Name: _________________________ Name: ___________________________
Address: _________________________ Address: ___________________________
_________________________ ___________________________
Phone: _________________________ Phone ___________________________
Fax: _________________________ Fax: ___________________________
The information may be used/disclosed for each of the following purposes:
At my request (only the patient can check this box)
For my health care
For payment/insurance
For employment purposes
Other:
This authorization shall expire no later than: ___/___/___ or upon the following event ________________________
(whichever is sooner), and may not be valid for greater than one year from the date of signature for Maryland medical
records.
I understand that after the custodian of records discloses my health information, it may no longer be protected by federal
privacy laws. I further understand that this authorization is voluntary and that I may refuse to sign this authorization. My
refusal to sign will not affect my ability to obtain treatment; receive payment; or eligibility for benefits unless allowed by
law. By signing below I represent and warrant that I have authority to sign this document and authorize the use or
disclosure of protected health information and that there are no claims or orders pending or in effect that would prohibit,
limit, or otherwise restrict my ability to authorize the use or disclosure of this protected health information.
____________________________________ __________________________________
Signature of patient (or patient’s Date
personal representative)
____________________________________ __________________________________
Printed name of patient representative Representative’s authority to sign for patient, (i.e parent,
guardian, power of attorney for healthcare, executor)
You have the right to revoke this authorization, except to the extent the custodian of records has relied on it, by sending your written
request to the Privacy Liaison, 3800 Reservoir Road, N.W. Washington, DC 20007.
Maryland Medical Records Release Form 1