Medical Records Release & Request Form

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Medical Records Release & Request Form

This form authorizes your health service provider to submit your medical record (or specific portions of it) to Mind Body Centers.

 

If you have any questions about this form, our staff is available during regular business hours (Mon – Fri, 8am – 5pm) to assist. Call us at 1-855-481-9605.

Patient Information

Patient's Name(Required)
Date of birth(Required)
Address(Required)

Release from Health Service Provider to Mind Body Centers

Provider Address

I am requesting the provider listed above to release the following information to Mind Body Centers:

The specific information to be used or disclosed is as follows:(Required)
(e.g. further care, insurance claim, attorney inquiry, at the request of the individual, personal use, etc.)

Select your Mind Body Centers Clinic:

Phone: 1-855-481-9605 | Fax: 1-888-388-0487

Disclosures & Authorization

I understand that the information in my health record may include information related to sexually transmitted disease, acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV). It may also include information about behavioral or mental health services, and treatment for alcohol and drug abuse. I understand that I have a right to revoke this authorization, in writing to Mind Body Centers, at any time. I understand that the revocation will not apply to information that has already been released in response to this authorization. If I fail to specify an expiration date, event, or condition, this authorization will expire in ninety (90) days. I understand that this authorization is voluntary. I can refuse to sign this authorization. I understand that I have a right to inspect and copy the information to be used or disclosed pursuant to this authorization. By signing below, I hereby authorize the above use and disclosure. (Signature of patient or Legally Authorized Representative.)
This authorization is valid until:(Required)
If I fail to specify an expiration date, event, or condition, this authorization will expire in ninety (90) days.
Date
Name of Legal Representative or Guardian if Patient is a minor