Release Medical Information ProviderWho is your Physician?Bart Price, MDPetra Travnicek, MD, FACPName Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Last Provider NameAddress Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code PatientName First Middle Last SSN#Date of Birth MM slash DD slash YYYY Records Authorized to be ReleasedRecords to be Released Admission history and physical Discharge summary Complete hospital chart Office notes Outpatient records Psychiatric and other mental health records Records relating to drug or alcohol abuse (must specify the extent or nature of the records to be released) Medication administration logs, dietary logs, staff contact or service logs, and other records that may not be part of my individual medical record, but which contain information relating to me (These records should be redacted to protect information pertaining to other patients.) OtherSpecifyExtent or nature of records to be released: (example, specific hospitalization or visit)This information will be used for the purpose of: Investigating an allegation of abuse Providing advocacy services Other activities at the request of the individual Legal representation Verifying my eligibility for services offered by the:Verifying my eligibility for services offered by the:This authorization will expire one year from the date of the signature below. I understand that I can revoke this authorization at any time by writing to the health care provider or to the provider below, but that revoking this authorization will not affect disclosures made or actions taken before the revocation is received. • I am not required to sign this authorization and that my health care or payment for care will not be affected by my refusal. • Federal privacy regulations will no longer apply to the information disclosed, and that may redisclose the information. • I am entitled to receive a copy of this authorization. • A copy of this authorization may be utilized with the same effectiveness as an original.Name of the Representative Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Middle Last Relationship to PatientPatient or Representative SignatureDate Month Day Year
