Patient Information: Patient information
Disclose Information to: Mark box if patient is completing the form and wanting records sent to themselves. If the records are to go to someone other than the patient, fill in who/where the records are to be sent to along with the address. Can be a person or another healthcare facility.
Disclosure by: Identify which facility you want records from (can mark more than one).
Information Disclosed: Identify specific records wanted -Make sure to note the dates of service needed/Approximate dates of service are fine.
Expiration: Fill in date/event. If nothing is filled in, the release if good for one time.
Signature of Patient/Legal Rep: have patient or legal representative sign the release form.
Signature of Patient/Legal Rep: have patient or legal representative sign the release form. This is for HIV/AIDS, Mental/Behavioral Health or Drug/Alcohol Abuse.