Medical Records Request Release Form



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Medical Records Request Release Form

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VA Form 10-5345 – Veterans Affairs

www.va.gov

payment, enrollment or eligibility on signing the authorization. VA may disclose
the information that you put on the form as permitted by law. VHA may make a. “
routine use” disclosure of the information as outlined in the Privacy Act system of
records notices identified as 24VA10P2 “Patient Medical Record – VA” and in.

Authorization for Release of Health Information (Including alcohol …

www.health.ny.gov

I, or my authorized representative, request that health information regarding my
care and treatment be released as set forth on this form. I understand that: 1. This
authorization may include disclosure of information relating to ALCOHOL and
DRUG TREATMENT, MENTAL HEALTH TREATMENT, and CONFIDENTIAL.

Request Pertaining to Military Records, SF 180 (11-15)

www.archives.gov

The Standard Form 180, Request Pertaining to Military Records (SF180) is used
to request information from military records. Certain identifying information is
necessary to … STRs must have the release authorization in Section III of the SF
180 signed by the member or legal guardian. If the appropriate signature cannot
be.

HIPAA Form – New York State Unified Court System

www.nycourts.gov

I, or my authorized representative, request that health information regarding my
care and treatment be released as set forth on this form: In accordance with New
York State Law and the Privacy Rule of the Health Insurance Portability and
Accountability Act of 1996. (HIPAA), I understand that: 1. This authorization may …

Consent for Release of Information – Social Security

www.ssa.gov

Request the release of medical records on behalf of a minor child. Instead, visit
your local Social Security office or call our toll- free number, 1-800-772-1213 (
TTY-1-800-325-0778), or. • Request detailed information about your earnings or
employment history. Instead, complete and mail form SSA-7050-F4. You can
obtain …

Authorization for Release of Protected Health Information – DHCS …

www.dhcs.ca.gov

DEPARTMENT OF HEALTH CARE SERVICES. PRIVACY OFFICE.
AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION. I,. ,
hereby authorize to. (Name of patient). (Name of person or facility which has
information) release the following health information: To: (Name and title or
facility name to …

Authorization to Release Confidential Information – Texas …

www.dshs.texas.gov

I authorize the following health care provider, attorney, counselor, school, etc.: _.
(Individual … I understand that: 1) I may revoke this authorization in writing by
contacting the DSHS office or program that obtained the authorization … This
form ( ) was read by me ( ) was read to me and I understand its meaning. All the
blanks …

Improving the Health Record Request Process for … – HealthIT.gov

www.healthit.gov

We also analyzed medical record release information and forms from 50 large
health systems and hospitals across the country representing 32 states. Then, we
talked to insiders —. ONC and partner stakeholders, as well as 4 medical record
fulfillment administrators — to unpack the records request process and look.

Authorization for the Release of Medical Information NIH-527

clinicalcenter.nih.gov

Authorization for the Release of Medical. Information. INSTRUCTIONS: Complete
this form in its entirety and forward the original to the address below: Please
complete a separate form for each requestor. NATIONAL INSTITUTES OF
HEALTH. ATTN: MEDICAL RECORD DEPARTMENT. MEDICOLEGAL SECTION.

Authorization to Release or Obtain Health Information HIPAA 402P

dhh.louisiana.gov

The Purpose of this Authorization is indicated in the box(es) below. (Place an “X”
in the box(es) that apply.) ❒ Further Medical Care. ❒ Personal. ❒ Legal
Investigation or Action. ❒ Changing Physicians. ❒ Research related treatment. ❒
Creating health information for disclosure to a third party. ❒ Other: (Specify) …

client consent to fax confidential information – Florida Department of …

www.floridahealth.gov

Florida law requires that information contained in medical records be held in strict
confidence and not be released without your written authorization. You must give
specific written authorization to release certain types of sensitive medical
information. The Florida Department of Health may fax confidential medical
information …

Release of Information Authorization – Danbury Hospital

www.danbury-ct.gov

AUTHORIZATION. I hereby authorize that the records described above may be
released to or received by Danbury Hospital for the purpose described above. I
understand that, if the recipient of the information is not a health care provider or
health plan covered by the federal Privacy Rule, the information used or
disclosed …

Authorization for Release of Information (HIPAA) – State of New Jersey

www.nj.gov

I authorize any health plan, physician, health care professional, hospital, clinic,
laboratory, pharmacy, medical facility, or other health care provider that has
provided treatment, payment, or services to me or on my behalf (“My Providers”)
to disclose my entire medical record and any other health information concerning
me to …

AR 023 – Alabama Department of Corrections

www.doc.alabama.gov

Apr 6, 2015 It is the policy of the ADOC to promptly respond to record requests, comply with
applicable federal and state laws regarding release of ADOC records, and
assess fees associated with the cost of providing … requests for inmate medical
records and collecting the applicable reproduction and delivery fees as …

authorization to release medical records/information – Victims …

crimevictimscomp.ga.gov

AUTHORIZATION TO RELEASE MEDICAL RECORDS/INFORMATION. THIS
AUTHORIZATION WILL BE VALID FOR THE DURATION OF THE CLAIM
APPLICATION. Pursuant … CVCP will not be able to render payment to or on
behalf of eligible victims/claimants if this consent form is not completed and
signed. The CVCP …

VA Request For and Authorization to Release of Medical Records or …

www.seattle.gov

AUTHORIZATION: I certify that this request has been made freely, voluntarily and
without coercion and that the information given above is accurate and complete
to the best of my knowledge. I understand that I will receive a copy of this form
after I sign it. I may revoke this authorization, in writing, at any time except to the …

Authorization to Release Medical Information – Ohio BWC – Ohio.gov

www.bwc.ohio.gov

Authorization to Release. Medical Information. Address. Injured worker name (
first, M.I., last). Employer name. Date of injury. State. City. Claim number. Nine-
digit ZIP code. I, the above-named injured worker, understand I am allowing the
Opportunities for Ohioans with Disabilities and the providers (persons or facilities
) …

Medical and/or Ambulance Records Request – City of Phoenix

www.phoenix.gov

Records will be provided within 15 – 45 business days of request receipt date.
You will receive a fax or email with instructions for payment. Please provide
complete information. Missing information may result in a delayed response to
your request. A separate form is required for each request. Notes: Ticket #: …