AUTHORIZATION TO RELEASE AND DISCLOSE PATIENT INFORMATION

AUTHORIZATION TO RELEASE AND DISCLOSE PATIENT INFORMATION
Patient Information
Patient Name*

First NameLast Name
Patient Date of Birth*

MonthDayYear
Date
Patient Phone Number*
Please enter a valid phone number.
Patient Email
example@example.com
Please select request type*

I am requesting CHEMED to send my medical/dental records to another medical practice/provider.I would like CHEMED to request my medical records from another medical practice/providerI am giving consent for CHEMED to verbally send or disclose my information with another individual/provider/practice.I am requesting CHEMED to send my medical/dental records to my personal account

Medical Records Release Form
Please enter person to receive records*
Full Name of individual/provider/practice*
Phone Number*
Please enter a valid phone number.
Fax Number*
Please enter a valid phone number.
Email Address
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
I would like the information to be sent or disclosed:

By First Class MailBy FaxBy encrypted emailVerbally to the Receiving Party noted aboveI would like to personally pickup records
You will be contacted when your records are ready to pick up
Enter Email or Phone Number to be contacted at
Information to be released - what you you want sent or released?
Select one of the following dropdown options:*

Complete health record, including: (check if the following apply)Only Behavioral Health treatment information (including substance abuse treatment information, if applicable)Only Dental recordsOnly OB/GYN related recordsOnly the items checked below:
Type of dental records

X-raysReferralsOther
Please select if applicable*

All substance use disorder treatment records.All HIV-related information.All behavioral health treatment information.Genetic Testing information.None of these apply
Please enter your initials:*
Please select

Demographic information (incl. identification and status asa CHEMED program patient).Diagnosis and related informationHistory & physical/Bio/Psycho/Social AssessmentDates of admission, services and dischargeTreatment plans(s)Types and frequency of servicesDischarge summaryTransition/after care/discharge planProvider notes and consultation reports (excluding psychotherapy notes)Test results and reports (other than toxicology)Prescription regimen/dosing RecordsBilling recordsBehavioral health treatment information (including substance abuse treatment information, if applicable)
Please enter your initials: *
If you would like to limit the dates of service to be provided, list dates of service here:
Dates of service from:

MonthDayYear
Date
Dates of service to:

MonthDayYear
Date
Purpose for Release (why is it needed?)

At my requestOther
This authorization lasts for one year after the date you sign it unless you enter a different date below:

Authorization for one year.Custom date
Custom authorization date:

MonthDayYear
Date
Date

MonthDayYear
Date
• This authorization may be canceled in writing at any time, by providing written notice to the Privacy Officer. A cancellation will not change releases that happen before the cancellation.
• The releasing provider will not restrict your treatment if you choose not to sign this authorization.
• A photocopy or other electronic copy of this authorization will be treated as an original.
• The releasing provider may have received health records from other providers which have been incorporated into your records at the releasing provider. If those records are included in those authorized above, they will be released.
• The releasing provider cannot prevent re-disclosure of your information by the person or organization that receives your records under this authorization, and that information may not be covered by state and federal privacy protections after it is released. By signing this authorization, you release the releasing provider from any and all liability resulting from a disclosure by the recipient.
Your signature below indicates you have read and understand this form, authorize release of your information as described above and have received a copy of this authorization form signed by you.
Signed by (signature of individual or legal guardian/legal representative)*

Clear
Name of individual or legal guardian/legal representative*
Relationship to individual/legal authority*
Sign date:*

MonthDayYear
Date
Patient Signature (for patients 14-18 years of age):

Clear
Sign date:

MonthDayYear
Date
Our address for sending documents:

1771 Madison Ave, Lakewood, NJ 08701

Click here to send via our secure portal

Tel: 732-364-2144

Fax: 732-364-3559
Should be Empty:

AUTHORIZATION TO RELEASE AND DISCLOSE PATIENT INFORMATION

Patient Information

Medical Records Release Form

Information to be released - what you you want sent or released?

If you would like to limit the dates of service to be provided, list dates of service here: