Request for Access to PHI

Patient Information

First Name

MI

Last Name

Date of Birth

Maiden or Other name

Medical Record Number

Email

Phone

Your Information

First Name

MI

Last Name

Email

Phone

Confirm Email

Confirm Phone

Mailing Address

Supporting Documentation

Your relationship to the Patient

Parent/Foster Parent

Guardian

Medical Power of Attorney

Executor of Estate

Document Upload

The facility has documented proof of my relationship to the patient on file i

I decline to upload supporting document(s) i

I will upload supporting documents(s) i

Upload supporting document(s) (Court Order or Medical Power of Attorney):

Information to Release

What to Release (check all that apply)

Release All of my records i

Medical Records Abstract i

Ambulatory Surgery Records i

Billing i

Consult Report(s) i

Discharge Summaries i

Emergency Department i

Full medical record i

Immunization List Only i

Laboratory Report(s) i

Operative Report(s) i

Pathology Report(s) i

Provider Notes i

Radiology Report(s) i

Radiology Image(s) i

From Date i

To Date i

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.

Mental Health Testing/Treatment (except psychotherapy notes) i

Alcohol/Drug Treatment/Testing i

HIV/AIDS Related Information i

Genetic Testing Information i

I authorize the disclosure of ALL sensitive information

I DO NOT authorize the disclosure of ANY sensitive information

Other Comments/Notes

Delivery Method

Released By

Please consider the environment. When possible, we will provide the information you requested electronically please check preference:

Receive electronic copy of records or Email i

Mail CD (If you choose this method there may be additional costs.) i

Mail Paper Records i

Fax i

Connect Patient Portal
Patients with an active electronic medical records account (patient portal) can request electronic delivery via secure web patient portal at no cost. Please confirm by checking the box above. i

The purpose(s) for which disclosure is authorized (check where applicable):

Patient’s request

Care at another facility/provider

Life Insurance

Legal

Disability

Worker's Comp

Today's Date

Consent Form Expiration Date i

Review & Submit

Cancel my request for records

Authorization for Release of Medical Information