How to complete this form instructions

Are you the patient?

Answer “Yes” if you are the patient or “No” if you are the patient’s legal or personal representative.

NOTE: If you answer “No, I am the patient’s legal/personal representative”, you will be asked to provide supporting documentation that gives you the authority to request medical records on the behalf of the patient.

Patient - please submit a copy of your drivers License or other government issued ID

Non-Patients – please submit a copy of your driver’s License or other government issued ID  AND a copy of valid supporting documentation that gives you authority to request records on behalf of the patient.

Acceptable forms of supporting documentation include:

-      Advanced Healthcare Directive (must be in effect at time of requesting records)

-      Death Certificate

-      Executor of the Estate (for deceased patients only)

-      Power of Attorney (must include a provision that allows medical decision-making and/or release of medical records)

-      Power of Attorney for Health Care (must include a provision that allows release of medical records)

-      or some other form of documentation (subject to final review)

Patient Information

Enter the patient’s First and Last Name, Middle Initial (if any), date of birth, full address, phone number, and the patient’s email address (required for contact purposes)

Who are you requesting information from ?

Please check either hospital and/or Clinic records.  If clinic records are being requested, please indicate from which doctors office you are requesting records from.

Where do you want the records sent to ?

o    Check the box if you want records sent to the patient only.

You can then skip to the next section if the recipient’s information is the same as the Patient Information.

o    If records will be sent to someone other than the patient, enter the recipient’s full name, address, city, state, zip code, recipient phone number, recipient fax and email.

What is the reason for the records request

o    Choose the appropriate reason for requesting records. Check only one (1).

What is the treatment(s)/service(s) date range you are looking for?

o    List the approximate date range for the treatment dates of service you need to the best of your ability.

What type of records do you want released (Check all that apply) ?

[  ] Clinic / Doctor office visit notes

[  ] Operative report(s)

[  ] Lab Test Result(s)

[  ] Pathology Report(s)

[  ] Radiology Reports (CT, MRI, X-Ray, Ultrasound, Cardiac Testing, etc..)

[  ] Sleep Study Report(s)

[  ] Hospital Stay Records

[  ] Other

Select other and please describe in your own words the specific medical records you are seeking if not listed above – be descriptive so we can help and respond more completely to your request.  For example: records related to a specific condition or surgery, specific testing results during a specific time period, ALL available records related to a specific stay…

Do we have permission to release the following protected information that may be contained in your records request?

Please check all that apply. Leave blank if none of them apply to the requested records.

 Signature and Date.

 A signature and date are required for the authorization to be valid.

If you are completing the authorization on behalf of the patient, also print your name and your relationship to the patient.

Thank you for selecting MISH Hospital and Clinics as your provider of choice.