Medical Record Release FROM ACV

Patient Name

First Name

Middle Name (optional)

Last Name

Birthday

Address

Address Line 1

Address Line 2

City

State

ZIP Code

Phone

Email

I would like copies of my health information indicated in the section below sent to:

Physician Office

Address

Address Line 1

Address Line 2

City

State

ZIP Code

I would like copies of my health information indicated in the section below sent from:

Radio Button

1525 E. Beltline NE Ste. 101 • Grand Rapids, MI 49525 • (o) 616.447.8220 • (f) 616.710.4048

I authorize the release of health information, contained in my medical records including:

Information regarding communicable diseases and infections as defined by the statue of Michigan Department of Health rules, which include venereal disease, Tuberculosis, Hepatitis A, B, C Human Immunodeficiency Virus (HIV), HIV testing Acquired Immunodeficiency Syndrome (AIDS), and AIDS related complex (ARC) Alcohol and drug abuse treatment information protected under the regulations in CFR 42 Part 2 Mental health treatment records, psychological services and social services information including communications made by me to a social worker, therapist, or psychologist

Entire Record Office Notes Cardiac Ultrasounds Vascular Ultrasounds Nuclear EKG

From

To

Disclosure Purpose

Attorney/ Legal Continue Patient Care Insurance Personal Use Worker’s Compensation

Other:

I understand the information released under this authorization may be re-released by the recipient.

This consent may be revoked at any time by writing to the address above, except for any actions that has already been taken in reliance upon it.

Expiration Date

Or Action

Unless otherwise stated this authorization will expire in 180 days from the date signed. Treatment, payment, or enrollment in a health plan will not be conditioned on signing this authorization for the covered entity’s own uses.

Signature of Patient or Legal Representative

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Date

Relationship to Patient If patient is a minor

Staff Only:

Witness

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Date/Time

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