Medical Records Release

Patients First name

Patients Last name

Patients Birthday

Month

Day

Year

Patient Phone

Patient Address

I. Authorization to Release Medical Records

I hereby authorize OnCall Pain to:

Authorize OnCall Pain to obtain my medical records from the person or organization listed below

Authorize OnCall Pain to release my medical records to the person or organization listed below

Name / Facility:

Facility Address

Facility Phone

Facility Fax

IV. Expiration and Revocation

This authorization will expire one year from the date of signature unless otherwise specified.

I understand that I may revoke this authorization at any time by providing written notice to OnCall Pain, except to the extent that action has already been taken based on this authorization.

V. Patient Rights and Acknowledgment

I understand that if my records are sent by fax or email, confidentiality cannot be guaranteed, and I accept this risk.
This authorization will expire one year from the date of signature, unless I revoke it in writing before then.
I understand that my medical records may include sensitive information such as HIV/AIDS status, sexually transmitted diseases, genetic testing, behavioral health, or substance use treatment, and I consent to the release of this information as indicated above.
I acknowledge that once my information is released, it may no longer be protected under federal privacy laws.
I understand that I am not required to sign this form to receive treatment, and that I may request a copy of this signed authorization for my records.

By signing below, I authorize OnCall Pain to release or obtain my health information as described on this form.

VI. Signature

Patient / Legal Representative:

Relationship (if not patient):

Signature

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