Authorization for Release of Medical Information

For use by a parent, or legal guardian, requesting medical records of a patient

Patient Information

First Name

MI

Last Name

Date of Birth

Email

Phone

Your Information

First Name

MI

Last Name

Email

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  

I have documentation to support my relationship to the patient and will provide it to the Madison Memorial Hospital representative today.   i  

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

 

Authorization to release my medical records

I authorize

Madison Memorial Hospital >Madison Memorial Hospital

Madison Surgery Center >Madison Surgery Center

Madison Memorial Rexburg Medical Clinic >Madison Memorial Rexburg Medical Clinic

Madison Memorial Orthopedics >Madison Memorial Orthopedics

Seasons Medical by Madison Memorial >Seasons Medical by Madison Memorial

to disclose to

Me

or to

Named person or entity

A fee for medical record copies may apply. A patient whose records are copied and sent to another healthcare provider for the purpose of continuing to receive medical care does not pay a fee for medical record copies. Requests for medical record copies for any use other than medical care will be billed. The HIPAA Privacy Rule permits healthcare providers to impose a reasonable, cost-based fee to an individual requesting a copy of medical records. The fee may only include the cost of labor, supplies and postage

Name

Email

Phone

Fax

Mailing Address

Information to Release

What to Release (check all that apply)

Medical Records Abstract   i  

Behavioral Health/Psychiatric Care   i  

Cardiology Report(s)   i  

Outpatient Clinic Note(s)   i  

Consultation Report(s)   i  

Discharge Summary   i  

ED Record   i  

Hospital Admission   i  

History and Physical   i  

Laboratory Results   i  

Operative Report(s)   i  

Outpatient/physician office record only   i  

Pathology Report(s)   i  

Physician Office Note(s)   i  

Radiology Report(s)   i  

Release ALL available records

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.

Psychological/Psychiatric conditions   i  

Drug and/or alcohol abuse diagnosis and/or treatment   i  

HIV AIDS diagnosis and/or treatment   i  

Sexually transmitted disease(s) diagnosis and/or testing   i  

Genetic Testing   i  

I authorize the disclosure of ALL sensitive information

I DO NOT authorize the disclosure of ANY sensitive information

Delivery Method

Released By

Receive electronic copy of records (this option is not available for radiology and cardiology images)   i  

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

Mail Paper Records   i  

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

Individual’s request

Medical Care

Insurance

Immunization

Legal

Today's Date

Consent Form Expiration Date  i  

Review & Submit for Signature

Cancel my request for records