Authorization for Release of Medical Records
ALL REQUEST MUST BE PICKED UP AT OFFICE BY REQUESTING PERSON FOR SIGNATURE VERIFICATION AS PER NY STATE HIPPA COMPLIANCE LAW.
Name of person making request and Relationship to Patie<br/>nt.
if other than self or parent please specify relationship.
Date range of records to be released. if specific info please specify type of info.
Immunization,Lab Results ,Radiology results, <br/>Consult Notes or Entire Records.
Transfer of Care, Continuation of Care, Legal or Other
TO BE PAID IN FULL AT PICK UP.
RELEASE DISCLOSURE; This Release Authorizes the disclosure of records for one year from date of the execution. I understand that these records are protected under Federal and/or State Law and cannot be disclosed without my written consent unless otherwise provided by law. I further understand that the specific type of information to be disclosed may , if applicable include: Diagnosis and treatment for physical and/ or mental illness, including treatment of alcohol or substance abuse, autoimmune deficiency syndrome (AIDS), aids related complex (ARC) or Human immunodeficiency Virus (HIV) infection for any admission.
I understand that I have the right to revoke this consent unless the facility which is to make the disclosure of information has already done so in reliance on the consent.
BY GIVING NAME AND DATE OF REQUEST YOU AGREE AND CONSENT TO THE AUTHORIZATION DISCLOSURE
TODAY'S DATE.
RECORDS WILL NOT BE RELEASED/ NOR FAXED UNTIL WE HAVE WRITTEN SIGNATURE OF APPROVAL FOR AUTHORIZATION AND PAYMENT IN FULL.
