To request records, please complete a records release form for each facility that you would like OnCall Healthcare to request records from.

• Initial Medical Exam
• Most recent Progress Notes
• Discharge Summary (If Any)
• Diagnostic Test Results (Labs, Imaging, Other)

• I understand by approving the release of information in the form of a fax, that confidentiality cannot be assured and I accept the risk that confidentiality may be breached.
• I understand that this authorization will expire 90 days from the date of my signature below. I hereby release OnCall Healthcare and any of their employees from any and all liability that may arise from this release of information.
• I understand information in my health record may include information relating to Sexually Transmitted Disease, Acquired Immunodeficiency Syndrome (AIDS), Human Immunodeficiency Virus (HIV) and other communicable diseases, genetic testing, Developmental/Behavioral Health/Psychiatric Care, and treatment of alcohol and/or drug abuse. My signature authorizes such release as indicated above.
• I understand that the information disclosed by this authorization may be subject to re-disclosure by the recipient and no longer protected by the Health Insurance Portability and Accountability Act of 1996 or other applicable federal and state law. However, re-disclosure by school officials may be subject to student education records privacy laws.
• I understand that if I agree to sign this authorization, I may keep a signed copy of the form. I understand that I am under no obligation to sign this form and that the person(s) and/or organization(s) listed above who I am authorizing to use and/or disclose my information may not condition treatment, payment, enrollment in a health plan or eligibility for health care benefits on my decision to sign this authorization. However, if my treatment is related to my participation in a research study, I understand that I may be refused treatment if I do not sign this Authorization.
• I have read and understood the terms of this Authorization and I have had a chance to ask questions about the use or disclosure of my health information. I authorize the named entity above to use or disclose my health information in the manner described above.

I have received, understand and accept ONCALL HEALTHCARE'S CONSENT FOR RELEASE OF MEDICAL RECORDS.