Medical Records Release Form

Patient Name*

Date of Birth*

Phone*

Email*

Address*

Street Address City State ZIP Code

This is to authorize the described medical records to the the above patient...

ARE YOU REQUESTING RECORDS TO BE SENT TO OR FROM NORTH CANYON MEDICAL CENTER?*

TO: NORTH CANYON MEDICAL CENTER
FROM: NORTH CANYON MEDICAL CENTER

How would you like your records to be sent?*

Patient to pick up at North Canyon in Gooding
Papercopy via Mail
Fax
E-mail

Fax number to send your records:*

Please enter where you would like the records to be released from:

Facility / Provider / Individual*

Address*

Street Address City State ZIP Code

Phone*

Fax

Records Requested (check all that apply)

Date(s) of Service: *

From:*

From:

To:*

To:

Please enter where you would like the records to be released to:

Facility / Provider / Individual*

Address*

Street Address City State ZIP Code

Phone*

Fax

Records Requested (check all that apply)

The following types of records require specific authorization: Each type must be initialed below for the request to be valid.

Psychiatric Notes

Initial To Authorize

Drug Addiction Treatment

Initial To Authorize

HIV Treatment

Initial To Authorize

Patient Photo or Driver's License Upload

Accepted file types: jpg, gif, png, pdf, Max. file size: 20 MB.

This authorization is valid for 90 days from the date signed unless a different date or event is specified here:

Patient Signature*

THIS AUTHORIZATION MAY BE REVOKED AT ANYTIME IN WRITING. TO REVOKE, THE PATIENT MUST SUBMIT A LETTER REQUESTING THE AUTHORIZATION BE REVOKED TO THE DIRECTOR OF HEALTH INFORMATION. RELEASING YOUR MEDICAL INFORMATION AS A RESULT OF THIS AUTHORIZATION MAY MEAN THAT YOUR MEDICAL INFORMATION COULD BE RERELEASED BY THE RECIPIENT AND NO LONGER BE PROTECTED BY FEDERAL PRIVACY RULES.

Date*

This is to authorize the described medical records to the the above patient...

Please enter where you would like the records to be released from:

Records Requested (check all that apply)

Please enter where you would like the records to be released to:

Records Requested (check all that apply)

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