Medical Records Release | Regional Primary Care

First Name

Last Name

Address Line 1

Address Line 2

City

State

Zip Code

Last Four Digits of Social Security Number

Phone Number

Email Address

Date of Birth

I hereby authorize and request Regional Primary Care, Inc. to use and disclose my personal, private Protected Health Information including release of a copy of my medical record or a specified portion of my medical record as indicated below on this form. I understand that the information I am authorizing Regional Primary Care, Inc. to release to the person, class of persons or organization named below may be re-disclosed and no longer protected by federal privacy regulations.

I understand that I may revoke this authorization at any time by in writing and that I may use a form furnished by Regional Primary Care, Inc. to make the written revocation. I also understand that if I revoke this authorization, my revocation will not affect any health information that was released according to the terms of this authorization before the date of my revocation. I also understand that I may not revoke authorized use and/or disclosures obtained in connection with my receipt of insurance coverage.

I understand that this authorization is voluntary, my treatment by Regional Primary Care, Inc. will not be conditioned on the completion of this authorization and I have a right to request and receive a copy of this authorization.

RELEASE TO OR RECEIVE FROM:

Release Receive No Records at this Time (Please check appropriate box)

Form Expiration

This Authorization is valid for one year from the date I sign it

This Authorization expires on the following date:

This Authorization expires when the following event occurs:

Date of Treatment

All Dates Specific Dates

The Information I am authorizing Regional Primary Care, Inc. to disclose is (Please check record and information to be disclosed)

Complete Records Physician Notes Lab Results Radiology Reports Immunization Records Medication Records Billing Information Other

I have read and understand this Authorization for Release of Protected health information and I have signed it voluntarily.

Printed Name of Individual or Personal Representative

*Psychotherapy Notes: This authorization does not include permission to release Psychotherapy Notes. Psychotherapy Notes are defined as notes that document private, joint, group, or family counseling sessions that are separated from the rest of an Individual/s medical record. If Regional Primary Care, Inc. maintains Psychotherapy Notes concerning me, I understand that I may authorize release of Psychotherapy Notes by means of a separate authorization that will be furnished if I require it.

Today's Date: 09/19/2024