Medical Records Request Form

* indicates a required field

  1. Patient Name*
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  2. DOB*
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  3. Street Address*
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  4. City*
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  5. State*
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  6. Zip Code*
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  7. Country*
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  8. E-mail*
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  9. I hereby give the following entity permission to release my Protected Health Information (PHI):*
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  10. I instruct the above named entity to produce the following information (Check ONE only):*


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  11. Invalid Input
  12. I authorize the above listed records to be released to the following entity:*
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    Name of person, team, or physician
  13. I authorize my records as specified be sent to:*
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    Fax or mailing address
  14. This authorization expires ninety (90) days from signature, or at the following event:
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  15. I am requesting my PHI to be disclosed for the following purpose:
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  16. HIV, Behavioral Health, or Drug and Alcohol Abuse/Treatment information contained within the dates of service I have specified above are to be released through this authorization unless specified below
  17. DO NOT RELEASE (Check all that apply):
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  18. I may revoke this authorization at any time by mailing or personally delivering a signed, written notice of revocation to the healthcare provider at which this authorization was executed. Such revocation will be effective upon receipt, except to the extent that the recipient has already taken action in reliance on this Authorization. I am entitled to a copy of this authorization upon my request. I may not be required to sign this Authorization as a condition to obtaining treatment or payment or my eligibility for benefits. The recipient of this protected health information is prohibited from re-disclosing the information unless the recipient obtains another authorization from me or unless the disclosure is specifically required or permitted by law. Where permitted, the information I am requesting to be disclosed may sometimes be redisclosed by the recipient and may no longer be protected by law. I am entitled to notice if my protected health information is used for marketing and results in remuneration to the provider. I hereby acknowledge that I have read and fully understand the above statements as they apply to me.
  19. Electronic Signature

  20. By selecting the "I Accept" button, you are signing this Authorization to Release Protected Health Information electronically. You agree your electronic signature is the legal equivalent of your manual signature on this Agreement. *
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  21. Full Name*
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  22. Date:*
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