Medical Release Form

HIPAA Authorization for use or Disclosure of Health Information
Patient Name*

First NameLast Name
Birth Date*

MonthDayYear
SSN:*
I hereby authorize Shore Cardiolgoy LLC to disclose and release healthcare information to the individual listed below.
Company/Individual Name*
Company/Individual Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Company/Individual Phone Number*

Area CodePhone Number
Company/Individual Fax Number

Area CodePhone Number
The following Information is requested*

All Health InformationA specific treatmentA specific range of datesA specific ConditionOther
Please specify particular treatment*
Date Range of Medical Records Requested*
Please specify particular condition*
Please specify other information you are requesting *
ALL REQUESTS WILL BE PROCESSED IN ACCORDANCE WITH APPLICABLE FEDERAL AND STATE LAWS

FEE SCALE: $1.00 per page for first 100 pages
$0.25 a page for remaining pages but not to exceed $200.00 Plus postage.
Records in other than paper media: Please inquire with Medical Records for pricing.

Copies will be provided within thirty days of a proper written request.
If records are being faxed there is no charge.
Patient/ Guardian Signature*

Clear
Should be Empty:

HIPAA Authorization for use or Disclosure of Health Information