Medical Records Request Form

Patient Name: *
Patient Email Address: *
Date of Birth: *
 /  / 
I receive my primary medical care at: *
I authorize the release of my information from: *
to the following person/facility: *
Address of Person/Facility: *
Fax number of person/facility: *
The purpose for utilizing or disclosing my personal health information is: *
Information to be released (please check all that apply): *
To: *
 /  / 
By signing below, I attest that I have read and understand the information above.
I may nullify this authorization (in writing) at any time unless Mary’s Center has already taken action based on this form
(or unless this authorization is given as a condition of obtaining insurance coverage and the insurer has certain legal rights to contest the policy or claim under the policy).
I understand that information disclosed based on this authorization may be re-disclosed by the entity or the person who receives the information.
I understand it is possible that the information no longer will be protected under federal medical privacy law.
I may refuse to sign this authorization and will not result in Mary’s Center denying me treatment.
I may inspect or copy the protected health information to be used or disclosed.
The use or disclosure of the requested information may result in the direct or indirect payment to Mary’s Center from a third party, including copying fees.:
Relationship to Patient: *
Phone Number: *
Please enter the text you see in the box.
Once the form is completed, Mary’s Center Medical Records Assistant will contact you once records are ready. It usually takes 5 to 7 business days to process the requests.
From: *
 /  / 


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