authorization for the release of medical...

Authorization for the Release of Medical Records Send to: MediCopy Services, Inc. 8 City Blvd., Ste 400 Nashville, TN 37209 • P: 615-780-2741 F: 615-780-9866 • [email protected] o All Records o Office/Clinic Notes o Operative Reports o Lab/Pathology Results o Radiology Reports o Physical/Occupational Therapy o Dates ________________________ to _________________________ o Other____________________________________________________ If you do not want certain portions of your medical records released, please check the categories listed below you would like excluded. o Substance Abuse, if any o AIDS/HIV/STDs, if any o Psychological/Psychiatric conditions, if any o Personal Use o Litigation/Legal o Insurance o Continuation of Care o Transfer to New Physician o Email o Fax o Pick-up at MediCopy o Postage (additional fee applies) Where are the records coming from? Facility/Doctor’s Name: Tell us about the patient. Name: DOB: SSN: XXX-XX- __ Email: Address: City: State: Zip: Phone#: Fax#: Where are we sending the records? Name: Email: Address: City: State: Zip: Phone#: Fax#: What would you like released? Purpose of Disclosure: Why are we sending the records? Delivery Method: How would you like the records sent? MediCopy will always provide medical records via encrypted email or fax. Please note that unencrypted email or faxing are not secure forms of communication and may therefore be at risk of being accessible by unauthorized individuals. By signing below, you are acknowledging that if you request an unencrypted delivery method you have been made aware of these risks. Patient’s Signature I hereby authorize MediCopy and its affiliates to release or disclose to the person(s) or organization listed above, all medical records requested, including any specially protected records such as those relating to psychological or psychiatric impairments, drug abuse, alcoholism, sickle cell anemia or HIV infection, unless otherwise noted. This authorization is valid for 12 months from the date of signature. I understand that I may cancel this request with written notification but that it will not affect any information released prior to notification cancellation. I understand that the information used or disclosed may be subject to re-disclosure by the recipient on this request and will no longer be protected by federal regulations. I understand I can refuse to sign this authorization and my healthcare provider may not condition treatment on my signing this authorization. Patient’s Signature: Date: Relationship to patient:

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Authorization for the Release of Medical Records

Sendto:MediCopyServices,Inc.8CityBlvd.,Ste400Nashville,TN37209•P:615-780-2741F:615-780-9866•[email protected]

oAll Records oOffice/Clinic Notes oOperative Reports

oLab/Pathology Results oRadiology Reports oPhysical/Occupational Therapy

oDates________________________to_________________________

oOther____________________________________________________

If you do not want certain portions of your medical records released, please check the categories listed below you would like excluded.

o Substance Abuse, if any o AIDS/HIV/STDs, if any o Psychological/Psychiatric conditions, if any

oPersonal Use oLitigation/Legal oInsurance oContinuationof CareoTransfer to New Physician

o Email o Fax o Pick-up at MediCopy o Postage (additional fee applies)

Where are the records coming from?

Facility/Doctor’s Name:

Tell us about the patient.

Name: DOB: SSN: XXX-XX- __

Email:

Address:

City:

State: Zip:

Phone#:

Fax#:

Where are we sending the records?

Name:

Email:

Address:

City:

State: Zip:

Phone#:

Fax#:

What would you like released?

Purpose of Disclosure: Why are we sending the records?

Delivery Method: How would you like the records sent?

MediCopywillalwaysprovidemedicalrecordsviaencryptedemailorfax.Pleasenotethatunencryptedemailorfaxingarenotsecureformsofcommunicationandmaythereforebeatriskofbeingaccessiblebyunauthorizedindividuals.Bysigningbelow,youareacknowledgingthatifyourequestanunencrypteddeliverymethodyouhavebeenmadeawareoftheserisks.

Patient’s Signature IherebyauthorizeMediCopyanditsaffiliatestoreleaseordisclosetotheperson(s)ororganizationlistedabove,allmedicalrecordsrequested,includinganyspeciallyprotectedrecordssuchasthoserelatingtopsychologicalorpsychiatricimpairments,drugabuse,alcoholism,sicklecellanemiaorHIVinfection,unlessotherwisenoted.Thisauthorizationisvalidfor12monthsfromthedateofsignature.IunderstandthatImaycancelthisrequestwithwrittennotificationbutthatitwillnotaffectanyinformationreleasedpriortonotificationcancellation.Iunderstandthattheinformationusedordisclosedmaybesubjecttore-disclosurebytherecipientonthisrequestandwillnolongerbeprotectedbyfederalregulations.IunderstandIcanrefusetosignthisauthorizationandmyhealthcareprovidermaynotconditiontreatmentonmysigningthisauthorization.

Patient’s Signature: Date:

Relationship to patient:

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