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Authorization For Release of Records

The document is an authorization form for releasing medical records. It contains the patient's name and contact information as well as details on what specific medical information is authorized to be released, to whom, and for what purpose. The form also notes that authorization can be cancelled at any time and expires after a certain date unless otherwise revoked.

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Christopher Hartman
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29 views

Authorization For Release of Records

The document is an authorization form for releasing medical records. It contains the patient's name and contact information as well as details on what specific medical information is authorized to be released, to whom, and for what purpose. The form also notes that authorization can be cancelled at any time and expires after a certain date unless otherwise revoked.

Uploaded by

Christopher Hartman
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Edward P. Tyson, M.D.


3811 Bee Caves Rd., Ste 200, Austin, TX 78746 Ph. (512) 380-9999 Fax: (512) 380-0072
www.EatingDisordersDoc.com

AUTHORIZATION OF RELEASE OF MEDICAL RECORDS


Patient Name:____________________________________________________DOB:___________________
Address:________________________________________City,State,Zip:____________________________
Phone Number:__________________________________
___ I authorize Dr. Tyson to Release
information to:

AND/OR

___ I authorize Dr.Tyson to obtain


information from:

_____________________________________
Name of Provider or Facility

___________________________________
Name of Provider or Facility

_____________________________________
Address

___________________________________
Address

_____________________________________
City, State, Zip

___________________________________
City, State, Zip

_____________________________________
Phone #/Fax # (include area code)

___________________________________
Phone #/Fax # (include area code)

Purpose of this Request:___________________________________________________________________


Specific Information Authorized (select one or more as appropriate):
___History & Physical
___Consultation Reports
___Operative Reports
___Radiology Reports
___Laboratory Results
___Pathology Reports
___Emergency Room Reports
___Other:________________________________
___Diagnostic Reports (i.e., EKG, EEG, Sleep Study)
I understand that:
I do not have to sign this authorization and that my refusal to sign will not affect my ability to
obtain treatment.
I may cancel this authorization at any time by submitting a written request to Dr. Tyson, except
where a disclosure has already been made in reliance on my prior authorization.
Release of HIV related information requires additional information.
Expiration of Authorization:
Unless otherwise revoked, this authorization expires ___________ (insert applicable date or event). If no date
is indicated, this authorization will expire 12 months after the date of signing this form
_____________________________________
Patient Signature

________________________
Date

_____________________________________
Guardian Signature

________________________
Date

Copyright 2010 Dr. Edward P Tyson, MD

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