Record Release Form

 

Contact us: (262) 347-1021

Do you need a copy of your medical records?

 

Please fill out the following form and return it to our offices via fax at 262-696-8403. There is a minimal charge for records.

 

White Administrative Services

Authorization to Disclose Health Information

Patient Name ____________________________________             Date of Birth _________________

Address: __________________________________________________________________________

City: ____________________________             State: _____          Zip Code: ___________________

Home Phone Number _____________________      Cell Phone Number ___________________

I authorize the use or disclosure of the above name patient’s health information as described below:

FROM: Dr. Cully R. White, Neurosurgery & Spine, SC    

8507 Solutions Center        

Chicago, IL 60677

                                       

TO:________________________________

 

INFORMATION TO BE DISCLOSED:

 Progress Notes                 Diagnostic Reports          Other (specify)__________________________

In compliance with WI Statutes, which require special permission to release otherwise privileged information please release medical records pertaining to: (check all that apply)

 Mental Health         Developmental Disability      Alcohol &/or Drug Abuse             HIV Test Results

 Other (specify) _______________________________________________________________________

PURPOSE FOR NEED OF DISCLOSURE: (check all that apply)

 Further Medical Care           Second Opinion       Personal File

 Claims Resolution                Other (specify) _____________________________________________

YOUR RIGHTS WITH RESPECT TO THIS AUTHORIZATION:

I have the right to ask for a copy of this authorization. I understand that I am under no obligation to sign this form and that White Administrative Services may not condition treatment or payment on my decision to sign this authorization. I understand that I have the right to withdraw this authorization at any time by providing a written statement of withdrawal to the Privacy Officer at White Administrative Services. I am aware that my withdrawal will not be effective until it is received by the Privacy Officer and will not be effective regarding the uses and/or disclosures of my health information thatWhite Administrative Services has made prior to receipt of my withdrawal statement. I understand that I have the right to inspect or copy the health information I have authorized to be disclosed by this authorization form. I understand my HIV test results may be released without authorization to persons/organizations that have access under State law and a list of those persons/organizations is available upon request. I understand that information used or disclosed based on this authorization may be subject to re-disclosure and no longer protected by Federal privacy standards. This authorization is good for a period of 90 days or until the following date____________.

 

 

PATIENT SIGNATURE ___________________________________________    DATE _______________

If someone other than patient:

LEGAL REP SIGNATURE _________________________________________   DATE _______________

 Parent of Minor        Legal Guardian        Spouse of Deceased             Other ____________________

Release Sent:_______________________________Records Sent:__________________________________

 

 

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