MEDICAL RECORDS RELEASE FORM
Click here to download a PDF of the Medical Records Release Form.


INSTRUCTIONS FOR AUTHORIZATION FOR USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION

PATIENT INFORMATION

(Who is the individual whose information you want released?)		 Include your full and complete name.  If you have a suffix after your last name (Sr., Jr., III), please provide it.  If you used a previous name, please include that information.  All these items are used to identify your health information and to make certain that only your information is sent.

CLINIC/HOSPITAL/
HEALTH CARE PROVIDER

(Who has the information you want released?)		 In this section, state who is sending your health information.  Please be as specific as possible.  If you want to limit what is sent, you can name a specific facility, for example Main Street Clinic.  Or name a specific professional, for example chiropractor John Jones.  Please use the specific lines.  Providing location information may help make your request clearer.

RECEIVING PARTY

(Where do you want the information sent?  Who may have the information?)		 Indicate where you would like the requested health information sent.  It is best to provide a complete mailing address as not everyone will fax health information.

INFORMATION TO BE RELEASED

(What do you want sent or released?  Check the appropriate box.)		 Indicate what health information you want sent.  If you want to limit the health information that is sent to a particular date(s) or year(s), indicate that in the date range.

SPECIAL CONSENT

If this section is left incomplete, information relating to this material will not be released.		 There are certain types of health information that require special consent by law.  Even if you check all information in the above section, you must also specifically request and sign for the information in this section in order for it to be released.

RELEASE INSTRUCTIONS

(How and When do you want the information?)		 A place has been provided to indicate a deadline for providing the health information.  Providing a date is optional.  Please indicate if you would like the health information mailed or faxed to the receiving party.  Fax transmissions are limited to 30 pages.  Health information may also be picked up at the Osceola location.  Hours for pickup are 7:00 a.m. to 5:00 p.m.  To arrange for pick up from the Scandia location, please contact Release of Information.

PURPOSE OF RELEASE

(Why is it needed?)		 Please indicate the reason for releasing the health information.