PATIENT INFORMATION

First Name *

Last Name *

Email *

Phone *

WHAT RECORDS WOULD YOU LIKE RELEASED?

All records or specific records *

All records

Records from specific dates

Specific record types

Specific date options

Last 2 years of records

Specific date range

Specify other records if needed

Should any records be excluded? *

Yes

No

Records to exclude

Substance Abuse, if any

AIDS/HIV/STDs, if any

Psychological/Psychiatric Conditions, if any

PURPOSE OF DISCLOSURE

WHERE ARE WE SENDING THE RECORDS?

Where should we send the records? *

Self

Outside Facility

Do you need to send records to multiple facilities?

Yes

No

Receiving Facility Name

Receiving Facility Phone Number

For each receiving facility, please list the facility name, the facility's phone number, and which records you want sent there.

Example: Facility 1 Name, 555-555-5555, X-Rays only; Facility 2 Name, 555-555-5555, All Records

DELIVERY METHOD

Do the different facilities you are sending records to require different delivery methods?

Yes

No

Delivery options are email, fax and postage

Delivery Method

Email

Fax

Postage

Additional fees apply to postage

Receiving Email

If sending to more than one location, please list each facility's email address.

Receiving Fax Number

If sending to more than one location, please list each facility's fax number.

Receiving Address

If sending to more than one location, please list each facility's mailing address.

Please list the delivery method (either email, fax or postage) and relevant contact information for each receiving facility.

Example: Facility 1 Name, email, [email protected]; Facility 2 Name, postage, 800 Fair Park Blvd., Little Rock, AR 72204

PATIENT SIGNATURE

Patient Signature *

Clear

Date *

Relationship to Patient *