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parent. legal guardian. Attorney in Fact under a health care power of attorney. . The records may be under the name of .The records may be under the name of .
am currently was formerly is currently was formerly a patient of . Enclosed is a signed Authorization to Release Medical Records. for insurance-related reasons. to obtain a second opinion. because of a change in providers. because of a relocation. for personal reasons. .
If there is a charge for copying the records, please submit a statement with the records and I will remit payment upon receipt of the records.
at the above address I can be reached by phone at or . An e-mail may be sent to . A fax can be sent to .
Thank you for your attention to this matter.
Sincerely,
Enclosure
AUTHORIZATION TO
RELEASE MEDICAL RECORDS
1. PATIENT INFORMATION.
| Name: |
| Address: |
| , |
| Date of Birth: |
2. AUTHORIZATION FOR RELEASE. I hereby authorize of , , , to release, disclose, and deliver the medical information described below to:
| Authorized Recipient: |
,
I do not give permission for any other use or redisclosure of this information.
| Dated: __________________________ |
| ________________________________ |
4. REDISCLOSURE. This release does not authorize redisclosure of medical information beyond the limits of this consent. The Recipient of this information is prohibited from using the information for other than the stated purpose, and from disclosing it to any other party without further authorization. The following written statement should accompany certain disclosures:
This information has been disclosed to you from records protected by Federal confidentiality rules (42 CFR Part 2 and 45 CFR Parts 160 and 164). The Federal rules prohibit you from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42 CFR Part 2 and 45 CFR Parts 160 and 164. A general authorization for the release of medical or other information is NOT sufficient for this purpose. The Federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse patient.
I specifically understand and agree that the REDISCLOSURE requirements set out above will apply to these records.
5. VALIDITY. I understand that this authorization will automatically expire from the date of my signature, and that I may revoke this authorization by sending a written notice to the person or entity authorized to make the disclosure described above. I agree that any release which has been made prior to revocation and which was made in reliance upon this authorization shall not constitute a breach of my rights to confidentiality.
I authorize the release of information as indicated above.
| Dated: __________________________ |
| ________________________________ |
File a claim with your health insurer or provider
Appeal the denial of a health insurance claim
Request information about the denial of a claim
Authorize the transfer of your medical records
Each medical office, hospital, or doctor is likely to have different rules about patient access to medical records. You may need to make a few phone calls to find out where your medical records are located and what the rules and procedures are for getting copies or having copies sent to another provider or hospital. Because there are laws protecting a patient's medical information, you may need to provide your request in writing. The Medical Records Request document makes that part of the process easy and quick.
In some cases, vaccination records may need to be explicitly requested separately from the complete medical records, such as when your child needs them for school enrollment. In that case, you might want to mention the need for the vaccination record separately in your request to the provider.
You can use the Rocket Lawyer Medical Records Request document to request your medical records if:
Different medical providers and hospitals have different requirements for requesting medical records. You might want to start the process by contacting the hospital to find out how to properly request medical records using the hospital's forms and procedures. You might even find the information on the hospital's website.
If the hospital requires that you send a written request for your medical records and it does not have a specific form for you to use, you can use the Rocket Lawyer Medical Records Request document to request your medical records from the hospital.
You are legally entitled to request your medical records at any time. However, state laws usually do not require medical offices to hold your records for more than about 10 years, so you may have to do a bit of persistent searching if a lot of time has passed.
The first step might be calling the doctor's office, if they are still open, and simply asking for a copy of your records. You may have to fill out a form or provide your own written request before copies of the medical records will be released to you. If you need to provide your own written request, the Rocket Lawyer Medical Records Request document can help you do just that.
You may want to include your legal name at the time of your last visit, the date of your last visit, and the duration of your stay (in the case of a hospital admission or surgery). In some cases, you may be lucky to have a doctor that holds onto all of their patients' records for an indefinite amount of time, in which case the process may be very straightforward.
If your doctor's office is no longer open, or they cannot locate your records, you may want to look into contacting your local health department. Doctors occasionally transfer files into a state storage facility when they retire. You might be charged a small fee to produce your records. You might even be charged a fee just to have someone look for them.
In the case of older records, you may have to provide additional information, such as your social security number or answers to questions that only you would know.
