MEDICAL RECORDS RELEASE FORM

PATIENT INFORMATION

Patient Name:

Chart Number:

Address:

Phone:

Date of Birth:

SSN: XXX - XX -

CONSENT TO RELEASE RECORDS

I do hereby consent and authorize Family Medical Center of Rocky Mount to release copies of my medical records.

Name of Person or Facility to Receive Records :

Address :

Date :

Phone :

Fax :

E-mail :

CONSENT TO OBTAIN RECORDS

I do hereby consent and authorize Family Medical Center of Rocky Mount to obtain copies of my medical records

Name of Person or Facility to Receive Records :

Address :

Date :

Phone :

Fax :

E-mail :

Please indicate date(s) or specific records to be released :

Please select how you would like the records to be released:

Delivery Preference :

Format :

PatientRights – I understand that:

1. I can cancel my permission at any time.I must cancel in writing and send or deliver the cancellation to releasing facility or Generations Family Practice. Any cancellation will apply only to information not yet released facility or practice.
2. This is a full release including information regarding alcohol/ substance abuse (in compliance with 42GFP, Part 2), genetic testing, mental health, HIV/ AIDS & other sexually transmitted diseases unless indicated above.
3. Generations Family Practice will not share or use my health information with out my permission other than listed in the Generations Family Practice Notice of Privacy Practices or as required by law. The Notice of Privacy Practices is available at generationsfamilypractice.com.
4. A fee may be charged for providing my protected health information by releasing facility/ clinician

Date :