Medical Release Form Δ AUTHORIZATION TO RELEASE MEDICAL RECORDS Release of Information to be sent to your previous primary care provider.Patient Name First Last Date of Birth MM slash DD slash YYYY Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Primary Phone #Secondary Phone #I authorize information released FROM: (please print)NameStreet AddressCity, State, ZipPhone #Fax #Please SEND MY RECORD TO: Where should we send your records? If you want your records sent to East Portland Pediatric Clinic, please type this information below: East Portland Pediatric Clinic 10000 SE Main Suite 30 Portland, OR, 97216 Phone: 503-255-3544 Fax: 503-251-6827 If you want them sent to a different practice, please replace the information below with that practice's details. Name(Required)Street Address(Required)City, State, Zip(Required)Phone #(Required)Fax #Purpose of Release Moving Insurance change Legal purposes Exchange of information Other Personal use ($30 fee applies) Dissatisfied with Clinic If checked "Other", please list belowType of Information To Be Released Transfer of Care Other If checked "Other", please list belowBy initialing the spaces below, I specifically authorize the release of the following medical records, if such records exist:Mental Health/TreatmentDrug Abuse Diagnosis/TreatmentAlcoholism Diagnosis/TreatmentAIDS/HIV Test ResultsSexually Transmitted DiseasesThe information to be used or disclosed pursuant to this authorization form may include information relating to: (1) acquired immunodeficiency syndrome (AIDS) or human immunodeficiency virus (HIV) infection: (2) treatment for drug or alcohol abuse: or (3) mental or behavioral health or psychiatric care. This authorization may be revoked at any time by notifying E.P.P.C. in writing. Unless revoked earlier, this consent will expire 180 days from the date of signing or shall remain in effect for the period reasonably needed to complete the request. I understand that any revocation will not have any effect on any information already used or disclosed before E.P.P.C. received the revocation. Records will be mailed within 30 days of receipt of completed authorization.Signature of Patient or Person Authorized by LawToday's Date MM slash DD slash YYYY Printed NameRelationship to Patient
