The Patient This Medical Records Release Form, in accordance with federal law (known as the Health Insurance Portability and Accountability Act or "HIPAA"), authorizes a patient, or their authorized representative, to obtain or release health care records and information from a medical office or other entity. Patient's Name First Last Person whose medical records are being released Patient's Date of Birth Do you know the Patient's Mailing Address? YesNo May be required by the holder of the Medical Records Street Address Address Line 2 City Please SelectAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWashington DCWest VirginiaWisconsinWyoming State ZIP Code Do you know the Patient's Social Security Number (SSN)? YesNo All information is kept confidential and protected on our servers. Patient's Social Security Number (SSN) The Requestor Who is REQUESTING the Medical Records? Who is REQUESTING the Medical Records? the PatientAuthorized RepresentativeParent / Legal GuardianOther Age of the Patient Years Old Requestor's Name Name of Authorized Representative Requestor's Name Name of Parent / Legal Guardian Authorization by Authorization by Having Medical Power of AttorneyLegal GuardianshipCourt OrderOther Authorization Type: The Releasor Who is RELEASING the Medical Records? Medical Records Request Medical Records being requested: Medical Records being requested: All Patient Medical Records and InformationOnly Specific Health InformationSpecific Start and End DatesOther Only specific Health Information related to: Start Date End Date I request the following Medical Records be released: Consent to Sensitive Records Do you consent to have the Medical Records released even if it contains sensitive information? Do you consent to have the Medical Records released even if it contains sensitive information? YesNo Such as physical or sexual abuse, alcoholism, drug abuse, sexually transmitted diseases, abortion, or mental health treatment. Do you consent to have the Medical Records released even if it contains HIV / AIDS related information? Do you consent to have the Medical Records released even if it contains HIV / AIDS related information? YesNo The Recipient Who will be RECEIVING the Medical Records? Sending Method I request the Medical Records are sent via I request the Medical Records are sent via Standard MailE-MailFaxOther (e.g. "pickup in person") Mailing Address Street Address Address Line 2 City Please SelectAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWashington DCWest VirginiaWisconsinWyoming State ZIP Code Fax Number E-Mail I hereby request the medical and health information to be transferred by: Purpose What is the PURPOSE of the release? What is the PURPOSE of the release? For Medical TreatmentFor Personal Reasons (Confidential)For a ClaimOther Reason for the request What is the Reason? Authorization Period This Medical Release will be valid until This Medical Release will be valid until an End Date (e.g. "1-year")an Event (e.g. "death") End Date Enter the Event Electronic Signature Do you want to sign this Medical Release online? Do you want to sign this Medical Release online? YesNo 100% free service Date of Release Sign and Date Patient's Signature Clear Please draw your signature. Authorized Representative's Signature Clear Please draw your signature. Parent / Legal Guardian Signature Clear Please draw your signature. Signature of Requestor Clear Please draw your signature. Signature Date Next Save Save and finish later
