Medical Records Release - Tennessee Valley OBGYN - Huntsville, AL Obstetrics & Gynecology

Patient Name(Required)

First Last

Date of Birth

Last Four Digits of SSN(Required)

Provider(Required)

Raiford

Callison

Holcomb

Office to RELEASE Information(Required)

Phone Number(Required)

Fax Number(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

PURPOSE OF REQUEST I authorize the entity above to disclose or provide PHI to the entity / individual(s) listed below.

Office to RECEIVE Information(Required)

Phone(Required)

Fax Number(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

Select All That Apply

Entire Patient Record

Financial / Billing / Insurance

Imaging (Ultrasounds, CT, MRI, etc)

Record of Mental Health or Substance

Office Notes

Lab Results or Pathology Reports

Record of HIV and/or STD Testing

Other

DESCRIPTION OF INFORMATION TO BE DISCLOSED

Purpose of Disclosure

Self / Patient Copy (See Charges for Records)

Transferring Out to Another OBGYN

Continuity of Care for Primary Care Provider, Specialist, Other Referring Providers

This authorization will expire at the end of the calendar year of the date signed unless you specify. You must renew or submit a new authorization after the expiration date to continue the authorization.

Date of Expiration

You have the right to terminate this authorization within 30 days by submitting a written request to our Practice Manager. Termination of this authorization will be effective upon written notice, except where a disclosure has already been made based on prior authorization provided.
We have no control over the person(s) you have listed to receive your PHI. Therefore, your PHI disclosed under this authorization may no longer be protected by the requirements of the Privacy Rule and will no longer be the responsibility of our practice.

Patient or Authorized Representative Signature(Required)

Today's Date(Required)

YOU HAVE THE RIGHT TO RECEIVE A COPY OF SIGNED AUTHORIZATIONS UPON REQUEST