PLEASE INCLUDE THIS FORM WHEN SENDING THE RECORDS!

 

Medical Records Release Request

 

I, the undersigned, authorize ________________________________________ to release information from my medical record. This authorization includes release of information concerning treatment of psychiatric/psychological conditions, drug and/or alcohol related conditions, and HIV or AIDS related conditions. Please release the following information:

The purpose of this request is for continued medical care. I would appreciate having these records faxed to Dr. Richard Levin at 502-589-3842 or mailed to his office at:

This authorization must be signed and dated, and may be revoked at any time except to the extent action has been taken prior to revocation. Revocation must be made in writing. This authorization will expire on ____________________. I hereby state that I have read and fully understand the above statements as they apply to me. I acknowledge that I understand treatment, payment, enrollment in any health plan, or eligibility for benefits are not conditioned on signing this authorization. I hereby authorize to the disclosure of the medical records to the purpose and extent stated above.

Medical Records Name: _________________________________
Current Name: _________________________________
Social Security Number: _________________________________
Date of Birth: _________________________________
Current Address: _________________________________
Current City, State, Zip: _________________________________
Home Phone: _________________________________
E-mail Address: _________________________________
Signature: _________________________________
Witness: _________________________________
Date: _________________________________



PLEASE INCLUDE THIS FORM WHEN SENDING THE RECORDS!