Release of Healthcare Information

Authorization to Release Healthcare Information
Patient Name*

First NameLast Name
Birth Date*

MonthDayYear
Gender*

MaleFemaleUndecided
Email*
example@example.com
Patient's Previous Name (if applicable)

First NameLast Name
I request and authorize my healthcare information to be:
Released to
Released from
INFORMATION TO BE PROVIDED (check one or more):*

All Medical Records and InformationBilling recordsHistory & PhysicalOutpatient RecordDischarge SummaryDiagnostic Test/ResultsAbstractOther
Do not include
Unless indicated above, I acknowledge that this request specifically includes medical, psychological, psychiatric, developmental-alcohol and/or drug abuse, human immunodeficiency virus (HIV) testing and treatment, AIDS related information, and genetic information if in the possession of MaxHealth ("MaxHealth").
Please include date(s) of service from: Date to Date (records will be provided for all service dates if left blank)
I request that the copy be provided (where possible/available):

In an electronic formatDiscuss my medical information onlyOn paperOther
If requesting an unencrypted format, by signing below you acknowledge that you understand the inherent risks involved with sendind and receiving information in an unencrypted, unsecured, format (such as regular email or unencrypted disc.) Such risks include misdirected messages, email intrusion, interception, or views by unauthorized parties. I understand there may be a fee for a copy of my health information. All fees will be in compliance with applicable law.
Patient Signature*

Clear
Date

MonthDayYear
Date
NPHCReleaseFormID
THIS AUTHORIZATION EXPIRES WHEN THE PATIENT IS NO LONGER UNDER THE CARE OF THE FACILITY REFERENCED ABOVE
Should be Empty:

Authorization to Release Healthcare Information