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Record Release Form
Administrator
2020-12-07T14:57:04-05:00
Record Release Form
Please complete all information.
Name:
*
First
Middle
Last
Date of Birth:
*
MM slash DD slash YYYY
Authorization for Use/Disclosure of Information:
*
I voluntarily authorize and direct my health care provider
Riaz Sibtain Syed, MD
to use or disclose my health information during the term of this Authorization to the recipient that I have identified below.
Recipient
Person or class of persons to whom my health care provider may disclose my health information:
Name:
*
Fax:
*
Address:
*
Street Address
City
State
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Purpose:
*
I understand that the specific purpose of this Authorization is
Coordination of Care
. (Note: “at the request of the patient” is sufficient if the patient is initiating this Authorization)
Information to be disclosed:
*
All of my health information that the provider has in his or her possession, including information relating to any medical history, mental or physical condition and any treatment received by me. (1)
All of my health information described above except for the following:
Only the following records or types of health information:
All of my health information described above except for the following:
*
Only the following records or types of health information:
*
Term:
*
This Authorization will remain in effect:
From the date of this Authorization until the day of:
Until the Provider fulfills this request.
Until the following event occurs: Written Revocation of Care
This Authorization will remain in effect from the date of this Authorization until the day of:
*
MM slash DD slash YYYY
Redisclosure:
*
I understand that once my health care provider discloses my health information to the recipient identified above, my health care provider cannot guarantee that the recipient will not redisclose my health information to a third party. The third party may not be required to abide by this Authorization or applicable federal and state law governing the use and disclosure of my health information.
Refusal to sign/right to revoke:
*
I understand that I may refuse to sign or may revoke (at any time) this Authorization for any reason and that such refusal or revocation will not affect the commencement, continuation or quality of my treatment by my health care provider.
Revocation:
*
Authorization will remain in effect until the term of this Authorization expires or I provide a written notice of revocation to my health care provider’s Privacy Office at the address listed below. The revocation will be effective immediately upon my health care provider’s receipt of my written notice, except that the revocation will not have any effect on any action taken by my health care provider in reliance on this Authorization before it received my written notice of revocation.
(1) Note: This Authorization does not extend to HIV test results, outpatient psychotherapy notes, drug or alcohol treatment records that are protected by federal law, or mental health records that are protected by the Lanterman-Petris-Short Act.
Signature
Signature
*
Date
*
MM slash DD slash YYYY
Signature of Witness
*
Guardian/Representative Signature
If Individual is unable to sign this Authorization, please complete the information below:
Name:
*
Legal Relationship:
*
Witness:
*
Date:
*
MM slash DD slash YYYY
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