FMCC Medical Release FROM - Fairfax Family Practice Centers

FAMILY MEDICINE OF CLIFTON/CENTREVILLE
6201 CENTREVILLE ROAD SUITE 100 CENTREVILLE, VA 20121 (703) 263-9600
AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS
**Please note that you will receive an invoice from Health Port that must be paid before records can be sent. Medical records
will be sent by mail ONLY.
__________________________________
Print patient’s full name
_________________________________
DOB (MM/DD/YY)
__________________________________
Street Address
_________________________________
Social Security Number
__________________________________
City, State, Zip Code
___________________ (H) _____________________ (D)
Home and Daytime Phone Numbers
At the request of the individual, I__________________________, do hereby authorize Family Medicine of Clifton/Centreville
to release:
Patient’s name
Dates of__________________________________________________________________________________________
_____Discharge summary
_____History & Physical
_____Progress Notes
_____Operative Notes
_____Pathology Reports
_____Laboratory Reports
_____Radiology Reports
_____ECG/EEG/Cardiac Cath
_____Emergency Reports
_____All Records
_____Other______________________
______________________
______I do _______I do NOT authorize release of information related to AIDS(Acquired Immunodeficiency Syndrome) or
HIV(Human Immunodeficiency Virus) Infections, psychiatric care and/or psychological
assessment and treatment for alcohol and/or drug use.
INFORMATION RELEASE TO:
________________________________________________________________
Name of Company/Agent/Facility/Person
________________________________________________________________
Street Address
________________________________________________________________
City, State, Zip Code
PURPOSE OF DISCLOSURE:
_____Referral to Specialist
_____Insurance
_____Legal Investigation
_____Disability Determination
_____Workers Comp
_____Personal
____Leaving Practice
____Continuing Care
Other (specify):____________________________________________________________________________________
I hereby authorize disclosure of health information for the above name patient. This authorization is valid for 12 months from the date of signature. I understand that I
may cancel this request with written notification but that will not affect any information released prior to notification of cancellation. I understand that the information
used or disclosed may be subject to re-disclosure by the person or class of persons or facility receiving it and would then no longer be protected by federal regulations.
I understand that the medical provider to whom this authorization is furnished may not condition its treatment of me on whether or not I sign the authorization.
_________________________________________________
Signature of individual or guardian (if person is under 18 years
of age) or personal representative of patient’s estate
_________________________________
Date
NOTE: There will be a charge for a personal copy or the permanent transfer of your records. Health Port has been contracted to
provide this service and will bill you directly. VA State rates apply. Pages 1-50 $.50/page. Pages. 51+ are $.25 each plus the cost of
first class postage.
ENTIRE___
LAB_____
IMMUNE____
OP_____
HP____
PATH_____
NUMBER OF PAGES_______
FOR USE BY SMART DOCUMENT SOLUTIONS REPRESENTATVIE ONLY
EKG___
DS____
___________________________________________________
X-RAY___
OTHER_____
ROI SPECIALIST
_____________________________
___________________________________________________
_____________________________
DATE