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Verisma Systems Inc
Authorization for Release of Medical Information
Authorization for Release of Medical Information
For use by a parent, or legal guardian, requesting medical records of a patient
For use by a parent, or legal guardian, requesting medical records of a patient
Patient Information
Patient Information
First Name
First Name
Please enter a value here
MI
MI
Last Name
Last Name
Please enter a value here
Date of Birth
Date of Birth
Please enter a value here
Email
Email
Please enter a value here
Phone
Phone
Please enter a value here
Your Information
Your Information
First Name
First Name
Please enter a value here
MI
MI
Last Name
Last Name
Please enter a value here
Email
Email
Please enter a value here
Phone
Phone
Please enter a value here
Confirm Email
Confirm Email
Please enter a value here
Confirm Phone
Confirm Phone
Please enter a value here
Mailing Address
Mailing Address
Please enter a value here
Please enter a value here
Please enter a value here
Please enter a value here
Supporting Documentation
Supporting Documentation
Your relationship to the Patient
Your relationship to the Patient
Parent/Foster Parent
Parent/Foster Parent
Guardian
Guardian
Medical Power of Attorney
Medical Power of Attorney
Executor of Estate
Executor of Estate
Surrogate
Sustituto / Sustituta
Document Upload
Document Upload
Please enter a value here
The facility has documented proof of my relationship to the patient on file
The facility has documented proof of my relationship to the patient on file
i
I decline to upload supporting document(s)
I decline to upload supporting document(s)
i
I will upload supporting documents(s)
I will upload supporting documents(s)
i
Upload supporting document(s) (Court Order or Medical Power of Attorney):
Upload supporting document(s) (Court Order or Medical Power of Attorney):
Authorization to release my medical records
Authorization to release my medical records
I authorize
I authorize
MaineGeneral Medical Center
>
MaineGeneral Medical Center
MaineGeneral Community Care
>
MaineGeneral Community Care
MaineGeneral Medical Center Medical Practice
>
MaineGeneral Medical Center Medical Practice
MaineGeneral Rehabilitation and Long-Term Care
>
MaineGeneral Rehabilitation and Long-Term Care
Facility or provider not listed above
>
Facility or provider not listed above
to disclose to
to disclose to
Me
Mí
or to
or to
Named person or entity
Named person or entity
Name
Name
Please enter a value here
Email
Email
Please enter a value here
Phone
Phone
Please enter a value here
Fax
Fax
Mailing Address
Mailing Address
Please enter a value here
Please enter a value here
Please enter a value here
Please enter a value here
Information to Release
Information to Release
What to Release (check all that apply)
History & Physical
i
Assessment/Care Plans/Notes
i
Discharge Summary
i
Emergency Room Record
i
Laboratory Reports
i
Office Notes
i
Operative Report
i
Psychiatric/Psychological Evaluation
i
Psychosocial Evaluation
i
Radiology Reports
i
From Date
Desde la fecha
i
Please enter a value here
To Date
Hasta la fecha
i
Please enter a value here
Disclosure of sensitive information
You have the right to refuse disclosure and prevent any other person from disclosing sensitive information related to the following conditions, treatments, or testing.
Include (Indicate by checking below): Please note that the information will not be released if not checked.
Psychological/Psychiatric conditions
Psychological/Psychiatric conditions
i
Drug and/or alcohol abuse diagnosis and/or treatment
Drug and/or alcohol abuse diagnosis and/or treatment
i
HIV AIDS diagnosis and/or treatment
HIV AIDS diagnosis and/or treatment
i
Genetic Testing
Genetic Testing
i
I authorize the disclosure of
ALL
sensitive information
I authorize the disclosure of
ALL
sensitive information
I
DO NOT
authorize the disclosure of
ANY
sensitive information
I
DO NOT
authorize the disclosure of
ANY
sensitive information
Delivery Method
Delivery Method
Released By
Released By
Electronic delivery (Secure download)
Electronic delivery (Secure download)
i
CD
Enviar por correo CD/DVD
i
Paper copy
Paper copy
i
The purpose(s) for which disclosure is authorized (check where applicable):
The purpose(s) for which disclosure is authorized (check where applicable):
My own records/use
My own records/use
Coordinating/managing my care
Coordinating/managing my care
Transferring care to another provider
Transferring care to another provider
Today's Date
La fecha de hoy
Consent Expiration Date
Consentimiento Fecha de vencimiento
i
Please Note
By signing this form, I acknowledge that MaineGeneral has privacy and security protections for my information, I understand that there are risks MaineGeneral cannot control. It is possible that my information could be read by a third party. I accept those risks by signing this form and allowing delivery of my records by mail or email.
I understand that:
Signing this Authorization is not required for receiving treatment, payment, enrollment and eligibility for benefits.
I can refuse to disclose some or all of the information in my treatment records. If I do so, it could result in improper diagnosis or treatment, denial of coverage, a claim for health benefits or other insurance, or other adverse consequences.
I can revoke all or part of this authorization at any time by delivering a written, dated and signed Notification. Or I can make an oral statement revoking this authorization to the facility listed above except to the extent that MaineGeneral Health has already acted in reliance on it. I am entitled to a copy of this authorization, upon request.
Information disclosed through this authorization may be shared again by the recipient and therefore no longer protected by privacy laws.
I can cross out any provision on this from with which I disagree.
Records are kept according to state regulatory guidelines. Some older records may not be available for release because they are beyond these retention periods.
Maine law allows reasonable fees to be collected for copies of medical records which may not exceed processing costs. MaineGeneral does not charge for copies provided for continuing care.
Review and Submit for Signature
Review and Submit for Signature
Cancel my request for records
Cancel my request for records
MaineGeneral VRA
Please Let the office staff for verify before submission
×
Patient Information
Name:
Email:
Phone:
Your Information
Name:
Email:
Phone:
Mailing Address:
Supporting Documentation
Your relationship to the Patient:
Parent/Foster Parent
Document:
The facility has documented proof of my relationship to the patient on file
AUTHORIZATION TO RELEASE MY MEDICAL RECORDS
Name:
Email:
Phone:
Mailing Address:
INFORMATION TO RELEASE
DISCLOSURE OF SENSITIVE INFORMATION
Psychological/Psychiatric conditions
DELIVERY METHOD
Consent Date:
IDENTITY VERIFICATION
Staff member
Note
×
If you need records to be sent to multiple locations/recipients or entities, please complete a separate form for each request. Thank you very much.