Request for Release of Medical Information

Patient Information
Information Requested

If only a portion of the record is required, please specify below:


Identify the date of service or date ranges requested including month and year

Record is to be released to the following individual:

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: 12/14/2019. Such expiration date or event has not occurred.

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

Kentucky Law directs health care providers to furnish to a patient, at the patient's request, one free copy of the patient's Medical Record. Additional requests for copies will be charged a rate of $1.00 per page.

Consent
By clicking Yes you agree to abide by the Terms of Service outlined above.
Please select a relationship
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.

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