Release of Medical Records

Please download, print, sign, and send the Medical Record Release form below to any provider who has medical records of yours that you would like Dr. Queenan to be able to review for your care, including your former primary care doctor.
Important: You may want to inquire about fees associated with a record transfer. If costs are prohibitive, please contact Dr. Queenan to determine which elements of your medical record are most valuable. Records received by Dr. Queenan can be returned to you after processing if desired.

Download printable Release of Medical Records here

AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION

Patient Name: ____________________________________________________________

Address: ________________________________________________________________

City: ______________________________ State: __________ Zip:__________________

Patient Phone #: ( ) __________________ Date of Birth: ______________________

I authorize Queenan Family Medicine and Maternity Care to release information to:

_________________________________
Name of provider or facility

_________________________________
Address

_________________________________
City, State, Zip

________________________________
Phone # / Fax # (include area code)

I authorize Queenan Family Medicine and Maternity Care to obtain information from:

1. Purpose of this request:

[check one]

_____ Healthcare
_____ Insurance Coverage
_____ Personal
_____ Transfer of Care
_____ Other

2. The type and amount of information to be used or disclosed is as follows:

[check one, and include dates where appropriate]

Immunization History
All medical records related to a specific illness or injury
(specify illness or injury and date(s) of treatment) __________________________ ___________________________________________________________________ Treatment Summary (includes history/physical, laboratory tests, X-ray reports, operative reports, pathology reports)
Specific information (select one or more, as applicable)
_____ Most recent history and physical
_____ Procedure report
_____ Most recent discharge summary
_____ Laboratory results from (date) ____________ to (date) _______________
_____ X-ray and imaging reports from (date) ___________ to (date) _____________
_____ Consultation reports from (doctor’s names) ____________________________ _______________________________________________________________
_____ Other (please describe) ____________________________________________
Entire copy of the record checked above

3. Additional authorization for sensitive information

I specifically authorize the release of information regarding the following condition(s):

Initials
_____ Substance abuse diagnosis and treatment, if any
_____ Mental Health services, if any
_____ HIV-related information, if any
_____ Sexually transmitted infections, if any

4. Authorization valid for:

[check one]

This request only
One year from the date of this authorization OR (insert date) ______________.
(This authorization applies to the records of the treatment received on or prior to the date of this authorization.)
This request and for medical records of any future treatment of this type described above until: (insert date) _______________.

5. I understand that:

- My right to healthcare is not conditioned on this authorization.

- I may cancel this authorization at any time by submitting a written request to the address provided at the top of this form, except where a disclosure has already been made in reliance on my prior authorization.

- I understand that the revocation will not apply to my insurance company when the law provides my insurer with the right to contest a claim under my policy. Unless otherwise revoked, this authorization will expire at the end of the pending of my claim or lawsuit.

- I understand that authorizing the disclosure of this health information is voluntary. I can refuse to sign this authorization. I understand I may inspect or copy the information to be used or disclosed, as provided in CFR 164.524. I understand any disclosure of information carriers with it the potential for an unauthorized re-disclosure and the information may not be protected by federal confidentiality rules. If I have questions about disclosure of my health information, I can contact:
U.S. Department of Health and Human Services Office of Civil Rights
200 Independence Avenue, S.W.
Washington, D.C., 20201
Phone: (866) 627-7748
Web: www.hhs.gov

- If the person or facility receiving this information is not a health care or medical insurance provider covered by privacy regulations, the information stated above could be redisclosed.

- Release of HIV-related information, information about sexually transmitted infections, mental health services, or substance abuse diagnosis and treatment requires additional authorization.

- There may be a charge for the requested records.

6. You are further authorized to discuss my case in detail with:

________________________________________________________________________
or their representatives, and assist them in any way they may request your services.

______________________________________________________________
Signature of Patient or Legal Representative

_____________________________________
Date

______________________________________________________________
If Signed by Legal Representative, Signature of Witness

_____________________________________
Relationship to Patient

A photocopy of this Authorization will be considered as an original.