Medical Records Request - Black River Family Health Practice

Patient Information

First Name: *

Middle Initial: *

Last Name: *

Date of Birth: *

To/From

Address *

City *

State *

Zip *

Phone: *

Fax: *

Period of healthcare covered

All Records

Records from (date) to (date)

Information requested or information to be used/disclosed:

Other

I give special permission to release any information regarding:

Mental health or psychiatric information

Purpose of Disclosure

Continuation of Medical care

Other

I have reviewed and I understand this Authorization. I also understand that the information used or disclosed pursuant to this Authorization may be subject to re-disclosure by the recipient and no longer be protected under federal law.

Patient/Patient Representative Signature *

Date: *

Patient Representative Authority/Relationship *

Initials of Sender: *

Witness Signature Signature *