Authorization for the Release of Information

Abstract

I hereby authorize/request (list facility) ___________________________________________________________________________________________ to release medical information of: Patient Name: ________________________________________ ________________________ _____ (Last) (First) (M.I.) Maiden/Former Name(s) (where applicable): ______________________________________________________ Date of Birth (MM/DD/YYYY): ________________________________ SSN: ____________________________ ________________________________________________________________ _________________________ Patient's Street Address, City, State and Zip Code Phone Number I request the following information be released:  All Medical Records  Primary Care Records (specify provider(s) or practice): _______________________________________  Specialist Records (specify provider(s), practice or specialty): __________________________________  Laboratory Reports  Pathology Reports  Itemized Billing Statement  Other (specify): _______________________________________________________________________ Test results and/or diagnosis and treatment information, if any, concerning substance use/abuse, psychiatric/behavioral health information, OBGYN records (include pregnancy test results), and AIDS/HIV and other communicable diseases contained within my medical records indicated above will be released through this authorization unless indicated below. Please initial information you DO NOT want released: _____ Substance Use/Abuse _____ Psychiatric/Behavioral Health _____ OBGYN Records _____ AIDS/HIV and other communicable diseases _____ Other (specify): _________________________ This request is limited to the following date(s) of treatment:  Date (MM/DD/YYYY): _____________________  Dates From (MM/DD/YYYY): ____________________ To (MM/DD/YYYY): _______________________  All Dates of Treatment This medical information is for the purpose of:  Self  Further medical care  Changing physicians  Attorney review  Disability  Workers Comp  Insurance Eligibility/Benefits  Litigation  Other (specify): ______________________