MHNWA Release of Medical Records

MHNWA Release of Medical Records
Release of Medical Records
Personal Information
Name

First NameLast Name
Birth Date

MonthDayYear
Social Security #
Phone Number

Area CodePhone Number
Alternate Phone Number

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
I request health information be released from:
Facility Name or Person
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number

Area CodePhone Number
Fax Number

Area CodePhone Number
Date Needed by

MonthDayYear
I request that health information be sent to:
Facility Name or Person
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number

Area CodePhone Number
E-mail
Date Needed by

MonthDayYear
Information to be released
Check all that apply

Inpatient/Hospital RecordsDischarge Summary
Other, please specify
Specific Dates/Years of Treatment
I specifically authorize the release of protected confidential information regarding:

Mental HealthDrug/Alcohol Abuse Treatment
I specifically authorize the release of protected confidential information regarding:

Current/Most Recent IEPPsychological EvaluationEducation Testing & School Records
Purpose of Access or Release
Admissions to ProgramMedical/Continuing Care
Other, please specify
Signatures

By signing below, I understand I am authorizing the use/release of my protected health information (PHI) and certify: My authorization is voluntary and the information given is accurate and complete to the best of my knowledge. This authorization is effective immediately and shall remain in effect for a period of one (1) year from the date of signature. I understand that I may revoke this authorization at any time by sending written notice, however, revocation will not affect any action previously taken in reliance on this authorization prior to receipt of my revocation. I further agree to release Micah 6:8 Ministries, Inc., its director, employees, and agents, as well as any facility honoring a request, from any and all liability resulting from the disclosure of the named patient’s medical records in reliance upon the authority contained therein.

Signature of Applicant
Printed Name of Applicant
Date

MonthDayYear
Signature of Witness
Printed Name of Witness
Date

MonthDayYear
Should be Empty: