Medical Records Request Request is for Request is for Entire Medical HistorySpecific Dates (start and end period) Start Date End Date Restrictions Will there be ANY LIMITATIONS on the Medical Information that is released? Will there be ANY LIMITATIONS on the Medical Information that is released? YesNo In case the Patient would like to restrict Mental Health Records, Communicable Diseases (ex. HIV, AIDS, etc.), Alcohol/Drug abuse, etc. Which items should NOT be released? Which items should NOT be released? Mental health recordsCommunicable diseases (including HIV and AIDS)Alcohol/drug abuse treatmentOther Please Specify The Patient Patient's Name First Last Patient's Name Requesting Party Who is Requesting the Medical Records? Who is Requesting the Medical Records? an Organization (hospital, medical office, etc.)a Person The party that will Receive the medical records. Business Entity's Name Individual's Name First Last Is this person related to the Patient by blood? Is this person related to the Patient by blood? YesNo What is the Relation? The Patient is their Releasing Party Who is RELEASING the Medical Records? Such as the Doctor, Medical Office, Hospital, or Insurance Company that is holding the medical records. Expiration When does this Medical Release expire? When does this Medical Release expire? Death of PatientSpecific Datean Event Select Date An event described as ___________ Effective Date When does this Release go into Effect? Next Save Save and finish later
