Medical Records

Patient's full name and date of birth (list any other names the patient may have had

Hospital Medical Record number (if available)

Specific information being requested (e.g., type of report/information and dates of service, etc.)

Purpose for which the information may be disclosed (personal records, continuation of care, etc)

To whom the information is to be sent (name, address, phone, fax number)

Specify authorization's expiration date if desired (see Release of Information form below)

All authorizations are valid for one year unless otherwise requested or revoked by the patient.

The patient's signature or a patient's legal representative's signature. Authorizations signed by a representative must contain a copy of the guardianship papers or power of attorney

Date of the signature.