Release Form General Medical Records Release and Authorization for Use of Disclosure of Protected Health Information Name of Patient First Middle Last Birthdate Date Format: MM slash DD slash YYYY Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone NumberE-mail I authorize and request the disclosure of all protected information for the purpose of review and evaluation. I expressly request that the designated record custodian of all covered entities under HIPAA identified above disclose full and complete protected medical information including the following: Spectacle Prescription Contact Lens Prescription All Records on File Records from last 3 years Other If other, please be specific:Expiration of the AuthorizationPlease initial one90 days after signature dateNo expirationsOn the date specified belowDate of Expiration of the Authorization Date Format: MM slash DD slash YYYY Please send information FROM:MICHAEL L MAGGARD OD 13930 7TH STREETDADE CITY, FLORIDA 33525 Phone: 352-567-8989 Fax: 352-567-0116Another addressAddress to send information FROM: Name of Provider/Clinic/Organization Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone Fax Please send information TO:MICHAEL L MAGGARD OD 13930 7TH STREETDADE CITY, FLORIDA 33525 Phone: 352-567-8989 Fax: 352-567-0116Another addressAddress to send information TO: Name of Provider/Clinic/Organization Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone Fax Please select how you would like your records transferred:Pick up RecordMail RecordsFax RecordsI understand that after the custodian of records discloses my health information, it may no longer be protected by federal laws. I understand the information released in response to this authorization may be re-disclosed to other parties. I further understand that this authorization is voluntary and that I may refuse to sign this authorization. My refusal to sign will not affect my ability to obtain treatment; receive payment; or eligibility for benefits unless allowed by law. By signing below I represent and warrant that I have authority to sign this document and authorize the use or disclosure of protected health information and that there are no claims or orders pending or in effect that would prohibit, limit, or otherwise restrict my ability to authorize the use or disclosure of this protected health information.Patients Signature (Parent or Legal Representative, if applicable)Date Date Format: MM slash DD slash YYYY Witness SignatureDate Date Format: MM slash DD slash YYYY If you prefer to print out this form and fill it out manually, it can be downloaded here.
