Permission to Disclose Medical Records

Name*

First Middle Last

Date of Birth

Last four digits of SS#

Any previous names under which records may be kept

First Last

Telephone number (if we have questions)

Sender

Who is to disclose the information?

Entity (please specify)*

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Phone

Fax

Who is to receive this information? (Central States Pain Clinic or other.)

Entity (please specify)*

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Phone

Fax

Check all that apply.

Purpose of Release

At request of the patient (or legal representative)
Discussion/coordination of care with family members involved with patient’s case
Transferring medical care to another health care provider.
For claims procession purposes (third party liability claims)
Other

Specify purpose of release:

What information should be released? Check all that apply.

Information

Records Date Range:

Please list specific records:

Specific Authorization for Release of Information Protected by State or Federal Law

I specifically authorize the release of information relating to:

I understand my healthcare and payment for my healthcare will not be affected by this authorization.

Signature

Relationship to patient if signed by a legal representative

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