Questions on how to complete each section of our Medical Records Release of Information form?
Follow these instructions
- Patient Name
Print the name, address and daytime telephone number of the patient whose records are being disclosed. Only one patient per form.
- Date of Birth
Enter month, day and year of patient’s birth.
- I hereby authorize _____________
This can be a name of any health care provider or facility who has the records to be released ( i.e. Dr. Jones or ADC. If only one Doctor name is listed then only that provider’s information will be released.) If information is being requested from another health care provider outside of ADC and you would like this information to be sent to ADC, then include complete mailing address and mail request to that provider. ADC does not mail the form.
- Date of Services
Time frame of selected information to be released. Can be one day or a range of dates or years. If no time frame is given, then the most recent two years of information will be released.
- Description of Information to be released
This is to guide us to select the proper documents to fulfill the request.
- Select types of information to be released
Select all that apply. If your ADC record contains information from another provider, please check the other box and write “outside records” and the name of the facility. Please understand that we will only have copies and they may not be complete.
- This information may be disclosed to and used by the following organization (the destination of the records)
Enter the complete name of person/physician/facility/company, along with the mailing address to receive the information, a telephone number is helpful. If records are needed by more than one person/facility, a separate request is required. If records are for yourself, please write your complete name and address. Include a contact telephone number.
- Description of the purpose of the use and/or disclosure
Reason for the request. Check all that apply.
- Expiration Date
Please enter an expiration date or event. If left blank, the authorization will automatically expire in 180 days. Do not use “indefinite”.
- Signature of Patient or Patient Representative
The patient or representative must sign the form.
Enter in date authorization is signed.
- Printed Name of Patient or Patient Representative
This is for verification purposes.
- Relationship to Patient
If you are a patient representative, please indicate your relationship to the patient. Except in the case of parents, we require a copy of the documentation appointing you as person with authorized access.
- Legal Authority
Legal guardian etc. We require a copy of the documentation appointing you as person with authorized access.
Do not email forms.
Patient forms must be faxed or mailed to the HIM department. Requests by third parties/insurance/attorneys must be mailed — the fax number it is for patient use only. Click here for where to FAX or mail forms.