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Ohio Medical Records Release Form 3

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This form is provided by The Family Medical Group in Ohio to authorize the disclosure or release of one person's protected health information.

Ohio Medical Records Release Form 3
Ohio Medical Records Release Form 3
3260 Westbourne Drive
Cincinnati Ohio 45248
Phone: (513) 389-1400
Ext 2501
Fax: (513) 619-8713
Authorization for
Release of Medical
Information
Patient’s Name:___________________________________________ Date of Birth:_________________
Address:______________________________________________________________________________
City/State/Zip Code: ____________________________________________________________________
SS#:________________________________ Patient’s Phone #: __________________________________
Date of Request: __________________________ Date Needed:__________________________________
I authorize The Family Medical Group
to release information to:
______________________________________
Name of Provider Facility
______________________________________
Address
______________________________________
City, State, Zip Code
_______________________________________________
Phone # / Fax # (Including Area Code)
I authorize The Family Medical Group
to obtain information from:
______________________________________
Name of Provider Facility
______________________________________
Address
______________________________________
City, State, Zip Code
_______________________________________________
Phone # / Fax # (Including Area Code)
PURPOSE FOR THIS REQUEST: (Check one) Specialist Transfer Other (Specify) ________
TYPE OF RECORDS REQUESTED: (Check one)
All medical records; or
I only want parts of my medical record, described below, to be disclosed:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
AUTHORIZATION VALID FOR: (Check one)
This request only.
One year from date of this authorization OR _______________ (Insert date) This Authorization Applies to the records of the
treatment received on or prior to the date of the authorization.
This request and for medical records of any future treatment of the type described above until: ____________________
(Insert Date)
Signature of Patient or Representative: ___________________________________________________Date:__________________
Relationship to Patient (if requester is not the patient)
_________________________________________________________________________________________________________
I understand that:
My right to healthcare treatment is not conditioned on this authorization.
I may cancel this authorization at any time by submitting a written request to the address provided at the top of this form, except
where a disclosure has already been made in reliance on my prior authorization.
I release The Family Medical Group staff and counsel from all legal responsibility or liability that may arise from authorized
release of information
If the person or facility receiving this information is not a health care or medical insurance provider covered by privacy regulations,
the information stated above could be re-disclosed. The Family Medical Group will not transfer this information without my
permission, unless the law authorizes or compels them to do so.
This authorization will include the release of information concerning HIV testing or treatment of AIDS, AIDS related conditions,
drugs or alcohol abuse, drug related conditions, alcoholism, and/or psychiatric or psychological conditions.
There may be a charge for the requested records. If you are requesting medical records that fall within the last 0-24 months there
will be no charge for the copying of these records. If you are in need of medical records that are older than 25 months see the
back of this form for our copying of medical records fees. These fees are based on the standard Ohio Statutes for copying of
medical records.
OR
Ohio Medical Records Release Form 3
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