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Medical records release of information instructions

Questions on how to complete each section of our Medical Records Release of Information form?

Follow these instructions

Instrucciones a cómo solicitar una copia de sus registros médicos.

  1. Patient Name
    Print the name, address and daytime telephone number of the patient whose records are being disclosed. Only one patient per form.
  2. Date of Birth
    Enter month, day and year of patient’s birth.
  3. 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.
  4. 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.
  5. Description of Information to be released
    This is to guide us to select the proper documents to fulfill the request.
  6. 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.
  7. 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.
  8. Description of the purpose of the use and/or disclosure
    Reason for the request. Check all that apply.
  9. Expiration Date
    Please enter an expiration date or event. If left blank, the authorization will automatically expire in 180 days. Do not use “indefinite”.
  10. Signature of Patient or Patient Representative
    The patient or representative must sign the form.
  11. Date
    Enter in date authorization is signed.
  12. Printed Name of Patient or Patient Representative
    This is for verification purposes.
  13. 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.
  14. 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 may be faxed or mailed to the HIM department. Requests by third parties/insurance/attorneys may be mailed or faxed. Click here for where to FAX or mail forms.