Release of Information Form
To request your medical records, complete the form below.
Instructions for completing the Release of Information Form.
This is a required field. This section is for patient information. Please fill out completely.
Person Authorized to Receive Information
This is a required field. This area is for whom you want to receive the information.
Dates of Health Care to be Released
This is a required field. This section must be completed from and to. This area may be as general as month/year to month/year or year-to-year but must be completed with a date.
Purpose of Request
This is a required field. There is an other field if none of the choices apply.
Type of Information to be Released
This is a required field. Please indicate what type of information you want to be released. There is an other line for any information that is not listed.
Time Limit & Right to Revoke Authorization
This is an area that you can complete a date or event for expiration of the authorization. If you do not complete a date or event, it will automatically expire in 180 days from the date signed. This area also contains an ability statement that is required but no response is necessary.
Drug and/or Alcohol Abuse, and/or Psychiatric, and/or HIV/AIDS Records Release
If this area does not apply, you do not have to complete it. (However, If there is ANY mention of this in the record, it will not be released).
You must initial the response or the entire authorization is no longer valid.
This is a required statement but no response is necessary.
Signature of Patient or Personal Representative Who May Request Disclosure
This area must be signed by the patient or proof of authorization to sign must be attached. (i.e.: Death Certificate with signer’s name on it as Next of Kin, Power of Attorney for health care with physician’s statement of patient’s inability to sign, court order giving guardianship.)
Relationship (if not the patient)
This is a required field for the relationship of the signer (i.e.: POA, parent (if the patient is under 18). A stepmother, grandmother, etc CANNOT sign an authorization for medical records unless they are court ordered as the guardian.
This is a required field. It is the date the patient signs the form.
Note: Information below the relationship and date line are for office use only.