HIPAA Medical Records Release Form

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Medical Records Request


In case the Patient would like to restrict Mental Health Records, Communicable Diseases (ex. HIV, AIDS, etc.), Alcohol/Drug abuse, etc.

The Patient

Patient's Name

Requesting Party

The party that will Receive the medical records.
The Patient is their

Releasing Party

Such as the Doctor, Medical Office, Hospital, or Insurance Company that is holding the medical records.


Effective Date

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