MEDICAL RECORDS
2720 Sunset Blvd., West Columbia SC 29169 • (803) 791-2264 • FAX: (803) 791-2136
Authorization for Release of Protected Health Information
Patient’s full name at the time of treatment:___________________________________________________________________________________
Date of Birth:________ / ________ / _____________ Social Security Number: ____ ____ ____ – ____ ____ – ____ ____ ____ ____
Date(s) of treatment: ____________________________________________________________________________________________________
Purpose of release: _____________________________________________________________________________________________________
I authorize the following provider/entity __________________________________________________________________ to release my health information to:
Recipient/Provider Name: _________________________________________________________________________________________________________
Telephone:_________________________________________________________ Fax:________________________________________________________
Address:______________________________________________________________________________________________________________________
City: _____________________________________________________________ State: _______________________________ ZIP: __________________
£ Portal £ Mail Record £ Pick-up £ FAX (to health provider only) £ I request a copy of this authorization
Information To Be Released: (Please check all that apply)
Reports/Notes Test Results/Studies Other
£ ED Notes £ Lab Tests £ Diagnosis List/Coding Summary
£ History & Physical Exam £ Pathology Reports £ Medication List
£ Consultations X-Ray/Radiology £ Immunization Record
£ Operative Reports £ Reports £ Billing Record
£ Discharge Summary £ Films (type):________________________ £ Patient Identification Sheet
£ PT/OT/ST Reports £ Entire Medical Record
Cardiac/Respiratory
£ Physician Office Note £ Abstract of Medical Record
£ Catheterization Report
Specify Practice:_____________________ £ Specify Other:_______________________
£ Echocardiogram
_________________________________ £ EKG _________________________________
£ Stress Test
£ Pulmonary Function Test
1. I understand that if my records contain documentation of alcohol abuse, psychiatric condition, drug abuse, or communicable diseases, this information will be released
as part of my record.
2. I understand that if the person or entity receiving this information is not covered by federal privacy regulations, this information will no longer be protected and may
be re-disclosed.
3. I understand that I may revoke this authorization at any time, but revocation will not apply to information that has already been released. Revocations should be sent
to the address noted at the top of the form.
4. I understand that I may refuse to sign this authorization and that my refusal to sign will not affect my ability to obtain treatment.
5. I understand that there may be a charge for obtaining the requested information. Information on the charge can be obtained by contacting the medical records
department noted at the top of this form.
6. I understand that a copy or FAX of this document is just as valid as the original document.
7. I understand that this authorization will expire 90 days after signed unless an earlier date is specified here _____________________________________________.
_____________________________________________________________ ___________________________ ______________________________________________
Signature of Patient or Authorized Person Date Contact Telephone Number
_______________________________________ ____________________________________________________________________________________________________
Relationship Reason Patient is Unable to Sign
7181-869-1 (6/18)
