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Memorial Healthcare System Medical Records

How to Complete an Authorization for Release of Confidential Medical Records Form

If You Are The Patient

the Authorization Form and complete it as described below.

If You Are a Minor or Are Requesting The Records of Your Child (Age 17 or Under)

Print the Authorization Form and complete it as described below.

If You Are The Next of Kin For a Deceased Patient

Print the Authorization Form and complete it as described below. Provide a copy of "Personal Representative of the Estate" documentation. If there is no estate, provide a copy of the death certificate or proof of the "next of kin" relationship.

If You Are The Legal Caretaker of a Patient

Print the Authorization Form and complete it as described below. Provide a copy of the "Healthcare/Power of Attorney" documentation as proof of the legal relationship.

If You Are a Family Member or Friend of a Patient

You must have the authorization of the patient to access, review or transport copies of patient information, or you must demonstrate that you have the legal authority to act as the patient's guardian or healthcare surrogate or proxy.

Filling Out The Authorization For Release of Confidential Medical Records

Print the Authorization Form and fill it out completely, as described below. (Incomplete forms will be returned to the requestor without the requested information.)

Section 1

Check off the name of the facility where the patient had services performed.

Section 2

Provide the patient's name and date of birth.

Section 3

Check off exactly what is needed from the patient's records or write a brief explanation of what is needed.

Section 4

Provide the name of the person/place to whom the records are to be released. (Only this person/place will receive this information.)

Section 5

Provide the date (Item b) that you want this authorization to expire and provide the purpose (Item g) of the release.

NOTE: This section states that by signing this Authorization Form, you are allowing for the release of any AIDS/HIV, mental or behavioral health, or drug or alcohol abuse information included in your record. If you do not want this information released with this request, you must specifically state this on your Authorization Form by crossing out Item c in Section 5.

Sign and date the Release. (Printed names are not accepted.) Mail or fax the completed Authorization Form to the facility where the patient had the services performed. Please include your telephone number.