Medical Records Request Form

Authorization for Release and Examination of Medical Records (PHI)
Patient Name*
Patient DOB*

MonthDayYear
Last 4 of Social Security Number*
Patient Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Choose One:*

I do not need or have any medical records to be released.I hereby authorize and request release of medical records and information (PHI) from the entity identified below to Jackson Family Practice, Inc:
Doctors Name*
Office/Clinic Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Office/Clinic Phone*
Office/Clinic Fax*
Specify Information to be Released:*

Entire Medical RecordOther (specify below)
Purpose for Disclosure:*

Personal UseChanging Primary Care ProviderContinuity of CareOther (specify below)
Timeframe of Records to be Released:*

AllSpecific timeframe (specify below)
From date*

MonthDayYear
To date*

MonthDayYear
I am aware that there may be information in this medical record that relates to substance abuse, mental illness, or HIV/AIDS that is of a highly confidential level. I give my specific authorization for these records to be release.

I am also aware that I can revoke this release at any time prior to the records being released to the above named entity and that this release is valid for one year after the date of execution. I understand that the information that I authorize to be released to a person or entity may be re-disclosed and no longer protected by the federal policy regulations.
Name Printed*
Today's Date*

MonthDayYear
Signature*

Clear
Today's Date*

MonthDayYear
Relationship
(eg. Self, Spouse, Mother, Father, Sister, Brother, etc.
Q
K
Bundle
Should be Empty:

Authorization for Release and Examination of Medical Records (PHI)