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

Patient Name(Required)

First Last

Date of Birth

Last Four Digits of SSN(Required)

Name of the Individual or Entity Requested to Release Information(Required)

Individual/Entity Address(Required)

Street Address Address Line 2 City State ZIP Code

Individual/Entity Phone Number(Required)

Individual/Entity Fax Number(Required)

PURPOSE OF REQUEST(who will be authorized to receive information) – I authorize the entity identified above to disclose or provide protected health information, about me to the individual(s) listed below. Who will be authorized to receive information (list the individual/entity that is to receive your PHI):

Individual/Entity Name(Required)

Individual/Entity Address(Required)

Street Address Address Line 2 City State ZIP Code

Individual/Entity Phone(Required)

DESCRIPTION OF INFORMATION TO BE DISCLOSED – I authorize the practice to disclose the following protected health information about me to the entity, person, or persons identified above:

Select All That Apply

Only Send the Following(Required)

Purpose of Disclosure(Required)

Patient Request

Other

Please Specify(Required)

This authorization will expire at the end of the calendar year of your last signature below, unless you specify an earlier termination. You must renew or submit a new authorization after the expiration date to continue the authorization. Please list the date of expiration if earlier than the end of the calendar year:

Date of Expiration

You have the right to terminate this authorization at any time by submitting a written request to our Privacy Manager. Termination of this authorization will be effective upon written notice, except where a disclosure has already been made based on prior authorization.
The practice places no condition to sign this authorization on the delivery of healthcare or treatment.
We have no control over the person(s) you have listed to receive your protected health information. Therefore, your protected health information disclosed under this authorization may no longer be protected by the requirements of the Privacy Rule, and will no longer be the responsibility of the practice.

Patient or Authorized Representative Signature(Required)

Today's Date(Required)

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