Release Of Information RequestForm

Patient Information

Patient First Name

Middle Name

Last Name

Maiden Name/Alias

Social Security #

Patient Birth Date

Who are you requesting records for

Self Minor Adult

Record is to be released to the following individual:

Name and Title

Phone Number

Email Address

Address Line 1:

Address Line 2:

City:

State:

Zip/Postal Code:

Reason for Request

Continued Medical Care Legal Purposes Insurance Purposes Personal Interest Other (Specify)

Delivery Method

Fax #:

**If you chose Fax as the delivery method. A valid mailing address must be entered in case the files can't be faxed due to their size.

The authorization must be signed and dated and may be revoked by notifying Hospital's Health Information Department in writing at any time except to the extent action has been taken prior to revocation. This consent will expire 60 days after the date beside my signature or sooner by my choice, in which case this consent will expire on this date or event: 12/23/2021. Such expiration date or event has not occurred.

REQUEST FOR RECORD COPY RELEASE WILL BE HANDLED ON A FIRST COME, FIRST SERVE BASIS.

Consent

I understand that the medical record released pursuant to this authorization could contain information concerning drug related conditions, alcoholism, psychological conditions, psychiatric conditions, and/or blood borne infectious disease, which are subject to federal and/or state restrictions on disclosure. I understand that if the person or entity that receives the information is not a health care provider or health plan covered by federal privacy regulations, the information described above may be re-disclosed and no longer protected by these regulations.  I hereby affirm that I have read and fully understand the above statements and consent to the disclosure of the medical record for the purpose and extent stated above.
 
If Norton Healthcare is asking to use/disclose my information, I understand that I may refuse to sign this authorization and that my refusal to sign will not affect my ability to obtain treatment, enrollment in any health plan, or payment/benefit eligibility.  I may inspect or copy any information used/disclosed under this authorization.

Yes

By clicking Yes you agree to abide by the Terms of Service outlined above.

Full Name

Date of Birth

Relationship to Patient

Required Documentation

Please select a relationship

Captcha Verification

PROHIBITION ON REDISCLOSURE: This information has been disclosed to you from records whose confidentially is protected by federal and/or state law. Federal and state regulations prohibits you (the recipient) from making any further disclosure without the specific written consent of the person to whom it pertains, or as otherwise permitted by such regulations. A general authorization for the release of medical or other information is NOT sufficient for this purpose.

Request for Release of Medical Information

REQUEST FOR RECORD COPY RELEASE WILL BE HANDLED ON A FIRST COME, FIRST SERVE BASIS.

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