Medical Records Request/Authorization for Release of Information

Patient Name: Patient Name: * First Last
Account Number:
Date of Birth: Date of Birth: * / MM / DD YYYY
Phone Number: Phone Number: - ### - ### ####
I authorize Oasis, the Center for Mental Health to release my medical record information:
Name/Facility:
Fax Email Discuss/Disclose (NO records sent)
Address: Address:
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Fax: Fax: - ### - ### ####
Email:
Information to be Released
Service Dates and/or Provider (Optional) :
I authorize Oasis, the Center for mental Health to release the following protected health information: *

I authorize Oasis, the Center for mental Health to release the following protected health information: Therapy Evaluation Psychiatry Evaluation All Therapy Notes All Prescription Management Notes Psychological Testing Report All Lab or Other Diagnostic Testing Communication Between Parties Entire Record
Include treatment regarding alcohol and/or substance abuse (if applicable):

Include treatment regarding alcohol and/or substance abuse (if applicable): Include Do Not Include
Purpose of request: *

Purpose of request: Personal Healthcare Payment/Insurance Employment Other Other
This authorization will expire one year from the date it is signed unless a shorter time is indicated here:
I understand that I have the right to revoke this authorization, in writing, at any time, except where uses or disclosures have already been made based upon my original permission. To revoke the authorization, I understand that I must notify Oasis, the Center for Mental Health in writing.

I understand that I have the right to revoke this authorization, in writing, at any time, except where uses or disclosures have already been made based upon my original permission. To revoke the authorization, I understand that I must notify Oasis, the Center for Mental Health in writing. Personal Healthcare Payment/Insurance Employment Other Other
I understand that I have the right to revoke this authorization, in writing, at any time, except where uses or disclosures have already been made based upon my original permission. To revoke the authorization, I understand that I must notify Oasis, the Center for Mental Health in writing. *

I understand that I have the right to revoke this authorization, in writing, at any time, except where uses or disclosures have already been made based upon my original permission. To revoke the authorization, I understand that I must notify Oasis, the Center for Mental Health in writing. Yes
I understand that it is possible that information used or disclosed with my permisson may be redisclosed by the recipient and may no longer be protected by federal or state privacy regulations. *

I understand that it is possible that information used or disclosed with my permisson may be redisclosed by the recipient and may no longer be protected by federal or state privacy regulations. Yes
I understand that uses and disclosures based upon my original permission cannot be taken back. *

I understand that uses and disclosures based upon my original permission cannot be taken back. Yes
I understand that there may be a processing fee for handling and submitting my request, and records requests may take up to 10 business days to process. *

I understand that there may be a processing fee for handling and submitting my request, and records requests may take up to 10 business days to process. Yes
I understand the following Medical Record Fees:

Insurance Companies & Public Offices
$22.88 Administration Fee
Charge of $0.76/ page
Charge of Postage (if mailed)

The Patient
Charge of $0.76/ page
Charge of Postage (if mailed)

An invoice will be provided by our staff when records are ready. Please call our office if you have any questions. *

I understand the following Medical Record Fees:

Insurance Companies & Public Offices
$22.88 Administration Fee
Charge of $0.76/ page
Charge of Postage (if mailed)

The Patient
Charge of $0.76/ page
Charge of Postage (if mailed)

An invoice will be provided by our staff when records are ready. Please call our office if you have any questions. Yes
Draw your signature into the box below. *

Clear
Today's Date: Today's Date: / MM / DD YYYY

Form Access

Medical Records Request/Authorization for Release of Information

Medical Records Request/Authorization for Release of Information

I authorize Oasis, the Center for Mental Health to release my medical record information:

Information to be Released