Fax: 916-734-2126. Like any other medical record, release forms are best managed electronically. Dates of treatment covered by this release: ˜ All dates, or ˜ Limited to the following dates: _____ ˜ All medical records and information/records received from other health care providers. You can: Review the information in your medical records. Medical professionals, financing agents, employers, and even faculty members need to submit a Release Authorization Form to allow themselves to access the information of a particular person. Medical Records & Release Forms. Please Note: The second page contains the fees for obtaining medical records. Mental health records may require special authorizations, signatures or releases. Download and print the appropriate form below or obtain a copy from our office. Please call our Health Information Management department at (217) 902-6500 for more information. AM/PM Option . Click for the Authorization to Release Medical Information form. Authorization for Release of Medical Record Information (Not to Be Used for a Patient Access Request) I hereby authorize Lee Health to release my protectedhealth information including information from my medical record which may include HIV (AIDS) testing, sexually transmitted disease, mental health and/or substance abuse services. Patient Name * Patient Date of Birth * - - Date . Medical Records Release Authorization Patient Name * First Name Last Name . This often involves a fee. AUTHORIZATION TO RELEASE MEDICAL RECORDS (This authorization complies with HIPAA) Printed Name of Patient (first, middle, last name) Birthdate (mm/dd/yyyy) Address (Street Address, City, State, Zip Code) Phone Number E-mail . Psychotherapy notes will not be included unless you provide separate authorization by initialing here ___. Complete all areas. Link to it on your website.

Dartmouth-Hitchcock keeps a private, secure medical record about your health.
This is the most common among these four sectors since employers are well-known for sending out an authorization to access their employees’ employment history, salary, and previous income statements. Minutes . Email: hs-roi@ucdavis.edu.

Fill out the Authorization to Release Protected Health Information form (PDF). This authorization is given in compliance with the federal consent requirements for release of alcohol or substance abuse records of 42 CFR 2.31, the restrictions of which have been specifically considered and expressly waived. The authorization will expire one year from the date signed unless otherwise specified. Front Desk Hours: Your Phone Number - Area Code Phone Number . You are authorized to release the above records to … To receive medical records, you must complete and submit the DMC Authorization to Release Medical Information. GENERAL MEDICAL RECORDS RELEASE AND AUTHORIZATION FOR USE OR DISCLOSURE OF PROTECTED HEALTH INFORMATION MS 100400 (12/2/15) *Note: If these records contain any information from previous providers or information about HIV/AIDS status, cancer diagnosis, Other Names Used . Jefferson Patients. You can use online forms for your medical releases in two ways. Your Date of Birth - - Monday -Day -Year . Follow these steps to complete the form: Enter the patient name (maiden or former name, if applicable), full address, birth date and medical record number (if known) in the upper right corner of the form. Patient Information . Paper release forms are a big headache for everyone. Patient First Name Patient Last Name . To get a copy of your medical records, you must complete an authorization form. Medical Records Release Authorization Please use this form in order to provide Orthopedic Associates records to an outside company or person. The benefits of electronic medical records are significant (they even save money). We would also be happy to fax or mail a copy of the release form to you.

To have your records sent to an outside provider, complete this form and press submit. Patient Phone Number * - Area Code Phone Number . I understand that I may revoke this authorization in writing to Athletico 600 Oakmont Lane, Suite C, Westmont, IL 60559 at any time and will be effective on the date notified except to the extent that action has been taken in reliance upon this authorization. Companies and employment .