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Personal Documents and Forms - Medical Records Release
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MEDICAL RECORDS RELEASE

THIS MEDICAL RECORDS RELEASE (the "Release") is made $month $day, $year.

TO:


______________________________, ______________________________, ______________________________, ______________________________, ______________________________, ______________________________,
Phone: ______________________________, Fax: ______________________________ and all employees, contractors, and associated individuals thereof;

TAKE NOTICE THAT I,  ________________________________________ (the "Patient"), do hereby request the following information be released:

Medical Records

1. All medical and health information contained within:

  1. Charts;
  2. Notes;
  3. Reports;
  4. Records;
  5. Medication lists, and other lists;
  6. Prescriptions;;
  7. Flowcharts;
  8. Emails;
  9. Memorandum;
  10. Orders;
  11. Lab results;
  12. Test results, and analysis;
  13. Information related to treatment for any sexually transmitted disease, including HIV or AIDS;
  14. Information related to treatment for mental health illnesses;
  15. Information related to treatment for substance abuse;
  16. Diagnostic images and reports, including but not limited to X-Rays and EKG tracings;
  17. Photographic images; and
  18. Digital recordings, including but not limited to digital images.

1.2  All information related to the accounting of the Patient’s files, including but without limitation to Statements of Account.

1.3 All other authorizations previously received for the release of any or all of the Patient’s medical information.

1.4 All of the above is collectively referred to as “Medical Records”, as represented on paper, kept in folders, digitally, electronically, or any other form.

1.5 "Medical Records" also includes production of any documents or material by physicians, nurses, chiropractors, dentists, therapists, counselors, consultants, technicians, and any and all staff of the organization to which this Release is directed.

Disclosure

2.  I ask that the Patient’s Medical Records be released to me, for my own personal use.

Time

3. I ask that the Patient's Medical Records be released within the next 30 days as required by the Health Insurance Portability and Accountability Act.

Notice and Additional Information

4. The contact information and particulars of the Patient are as follows:

Name:

________________________________________

Date of Birth:

$month $day, $year

Street Address:

________________________________________

City/Town:

________________________________________

State:

________________________________________

Country:

________________________________________

Postal/ZIP:

________________________________________

Home Phone Number:

________________________________________

Cell Phone Number:

________________________________________

Email:

________________________________________

Duration of Medical Records Release

5. This Release will be valid until such time that you receive written notice from me revoking this Release, or until $month $day, $year.

Continuance of Ongoing or Future Care

6. This Release does not affect any ongoing or future care of the Patient.

SIGNED at ________________________________________, in the presence of:




______________________________
WITNESS




__________________________
PATIENT/LEGAL REPRESENTATIVE

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