United Critical Care Lung & Sleep Medicine

Available Forms

MEDICAL RECORDS RELEASE FORM New Patient Form

MEDICAL RECORDS RELEASE FORM

PATIENT?S NAME: *

Please add FULL LEGAL NAME

DATE OF BIRTH *

UNITED CRITICAL CARE LUNG-SLEEP MEDICINE IS AUTHORIZED TO (CHECK ALL THAT APPLY) *

RECIPIENT/ DISCLOSER *

FOR THE PURPOSE OF *

I AUTHORIZE RELEASE OF THE FOLLOWING MEDICAL RECORDS (Check One) *

COMPLETE MEDICAL RECORD including information and copies of records relating to the history, diagnosis, treatment or services rendered to me in connection with any condition or disease. This includes permission to release potentially sensitive information which may include information concerning my treatment of mental illness, HIV, alcoholism, drug us/ dependency, venereal disease, sexual assaults, abortion, illegitimacy birth, communications to social workers and/ or psychotherapists, psychologists, if any.

IF PARTIAL

Please specify information that can be released) on the lines below.

WHERE WOULD YOU LIKE FOR RECORDS TO BE SENT?

Kindly include the provider's name and fax number. For personal records, please provide the email address for delivery.<br/><br/>PLEASE SPECIFY IF YOU WOULD LIKE RECORDS PRINTED OUT FOR A $0.60 CHARGE PER PAGE.

I RELEASE UNITED CRITICAL CARE LUNG-SLEEP MEDICINE Inc. and the recipient/discloser listed above and any of their providers and staff from all responsibility and liability that may arise from this authorization. I may withdraw this authorization at any time by giving written notice to United Critical Care Lung-Sleep Medicine Inc, provided that I do so in writing and to the extent that you may have already disclosed the information in reliance on this authorization. *

Type Full Name for Patient Signature (Patient?s Representative if patient is a minor)

Today's Date *

* Required field