Authorization to Disclose Health Information An outside third party processes all of our medical record requests. It may take up to 14 business days to process your request. PATIENT INFORMATIONWho is making the request?(Required) I am either the patient or the patient's legal guardian filling out this form. I am an authorized third party requesting these records. (NOTE: We must have a signed release form to process these requests) Patient Name(Required) Previous Name Date of Birth(Required) Phone(Required) Email(Required) Enter Email Confirm Email Address(Required) Street Address City StateAlabamaAlaskaAmerican 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 Please upload a copy of your ID (drivers license) or legal document (POA, guardianship, etc) for identity verification(Required) Drop files here or Select files Max. file size: 10 MB. RECORD REQUEST INFORMATIONRecipient:(Required) Release to Patient Release to: Company Name(Required) Company Contact Phone Number(Required) Fax Number(Required) Email Address(Required) City(Required) State(Required) Zip Code(Required) Method of Delivery(Required)NOTE: If radiology images are requested, a CD with those images must be mailed out. Electronic Delivery Paper Copies (additional fees may apply) Date of Service(Required) Last 2-years only Only the following dates: From this date(Required) Through this date(Required) Records to be Released(Required)NOTE: We do not release other facilities' records, only Tri-City Orthopaedics. Pertinent Package (History & Physical, Operative Report, Radiology Report, Clinic Visit) Itemized Billing Radiology Image(s) (CD to be mailed, please allow 3 additional business days to process) Therapy Other Please specify(Required) Purpose of Disclosure(Required) Personal Use Continuation of Care/Treatment Legal/Injury Other Please specify(Required) I Consent to the Following:(Required) I understand that this authorization is good for this request only. Any other requests for medical records will require another form to be submitted. Printed Name of Patient or Legally Authorized Representative(Required) Date Signature of Patient or Legally Authorized Representative(Required)The signature below has been signed electronically
