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RELEASE OF MEDICAL RECORDS REQUEST (OUTSIDE FACILITY)
All Fields Are Required
Last Name:
Address:
First Name:
City:
Date of Birth:
State:
-- Select State --
AA
AE
AK
AL
AP
AR
AS
AZ
CA
CO
CT
DC
DE
FL
FM
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MH
MI
MN
MO
MP
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
PR
PW
RI
SC
SD
TN
TX
UT
VA
VI
VT
WA
WV
WI
WY
Soc. Sec. Num:
(optional)
Zip:
Telephone:
I (
name of patient or legal representative
)
, hereby authorize and give consent to:
and its respective agents and employees, at:
phone:
fax:
to furnish the medical record compiled during my (
patients name if other than self
)
's treatment of
on or about:
.
In doing so, I hereby release the Hospital/Facility from all legal liability that may arise from the release of this information.
I permit this confidential information to be released
ONLY
to the following person, agency or organization whose name and address I provide at
MEMORIAL SLOAN KETTERING
CANCER CENTER
:
phone:
fax:
I limit the information to be released to the following items: (
Please check the appropriate boxes
)
No Limitation: Including any treatment for alcohol, dependency or psychiatric evaluation
Limitations (specify):
Abstract: Discharge Summary, Report of Operation, Pathology Report, Radiology Report
Radiation Records: Including consult note, treatment records, simulation films and weekly port films.
Lab Results:
Radiology Reports:
Radiology Films:
Pathology Reports:
Pathology Slides:
Other:
I permit this confidential information to be released
ONLY
to the following reasons or purposes:
Continued Treatment or
Other (Specify):
This authorization to release confidential information may be revoked by me, in writing at any time, except to the extent that action has already been taken; shall be effective only long enough to answer the purpose for which it is given, and no further' confidential information will be released without the execution of an additional written authorization.
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By signing this authorization form, you authorize the use or disclosure of your protected health information as described above. This information may be redisclosed if the recipient(s) described on this form is not required by law to protect the privacy of the information, and such information is no longer protected by federal health information privacy regulations.
I have voluntarily completed this authorization for release of medical information and understand that it is not consent for treatment and will not affect any future treatment that may be sought at
.
I have been advised of any photocopy fees that I may be required to pay in advance of the release of this requested information.
Signature of patient or legal representative
Signed Date