Patient Name

DOB

Who you would like to authorize to disclose your records: e.g. Revere Health, Dr. Olsen, Family Medicine, etc.

Who to disclose to:

Your own name (if getting record for self)

Your spouse, children, etc. (if you want to allow others access to your records in case of emergency)

The facility you are sending your records to (new physician, The VA hospital, etc.). Make sure to write down a phone and/or fax number for us to send the records to.

Dates of Service: If you would like all dates of service, write 'all' on both [to and from] lines; or you may choose a time frame using start date to final date you would like released.

Purpose of Disclosure: This is somewhat flexible, but examples we get are: personal records; transfer of care; going to specialist; etc.

Expiration Date: This form automatically expires in one year, meaning whomever you allow access to may have access for one year. If you only want a specific time, you must put a date in the expiration date location. HIPAA law requires an actual date, e.g. 01/01/3000 or 10/14/2015. Otherwise, if left blank, the authorization will be valid for one year.

Signature of authorized party.

Date

HealthPort is the premier provider of health information services and solutions. With a team of more than 3,500 employees, HealthPort processes over 45,000 medical record requests daily for well over 10,000 healthcare facilities across the nation.

HealthPort will send your records via first class U.S. mail in a 9 X 12 envelope marked confidential.

The charges for the copies you request are typically regulated by each state. HealthPort abides by the allowable rates set forth by each state.

(Fast and Efficient) to remit payment online, please go to www.HealthPortPay.com and make sure you have your enclosed invoice payment for these services. HealthPort accepts Visa, MasterCard, American Express and Discover.

To remit payment by check, please include the bottom portion of the enclosed invoice and send to the address listed.

To remit payment by phone, please contact a payment representative at 1-800-464-0035 and make sure you have your enclosed invoice handy as well as a major credit card listed above.

This medical facility utilizes services of HealthPort to handle the fulfillment of all requests for medical records. If you choose to request your records from this facility, please know that HealthPort will be processing and fulfilling your request.

Simply complete an authorization release of your records at the facility, and HealthPort will handle the rest. Please do not attempt to contact HealthPort to request your records. Your request must be sent directly to the medical facility.

When you request your medical records, you will receive a copy of the original records located in the medical facility. There are many steps taken to provide copies of the medical records, and the process is labor-intensive. The records must be located from various places within the facility, the chart pulled, the records are then selected based on the dates or treatments requested, the authorization is validated, the records are reviewed for legibility and to ensure confidentiality, copies are made of the appropriate pages, each page is replaced in the chart exactly how it was found, the chart is then filed or put back into storage and the package is sent per your request.

There is no need to go to or contact the healthcare facility from which you requested your records in order to make payment. The healthcare facility will not be able to assist you with your invoice payment for these services.