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