OnCall Healthcare Medical Records Release Consent
Please complete a records release form for each facility that you would like OnCall Healthcare to release records to.
AUTHORIZATION FOR USE OR DISCLOSURE OF HEALTH INFORMATION FROM:
OnCall Healthcare 222 South Mill Avenue Suite 800 Tempe, AZ 85281 Fax: (888) 518-4950 Email: healthcare@oncallhc.com Web: www.oncallhc.com
PATIENT REQUESTING MEDICAL RECORDS?
First Name
Last Name
Date of Birth
INFORMATION TO BE RELEASED
Initial Medical Exam
Most recent Progress Notes
Discharge Summary (If Any)
Diagnostic Test Results (Labs, Imaging, Other)
Please list any additional records information that you would like us to send.
AUTHORIZATION FOR USE OR DISCLOSURE OF HEALTH INFORMATION TO:
Where would you like your records to be sent?
Provider or Facility Name
Office Email
Office Address
Office Telephone Number
Office Fax Number
AUTHORIZATION
This information, including diagnosis and record of any examination and treatment rendered to me, to include any Federal or State protected information, drug and/or alcohol abuse information and Human Immunodeficiency Virus test results (Aids and related conditions).
I understand by approving the release of information in the form of a email or 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 (Section 1) to use or disclose my health information in the manner described above.
I understand that copies of medical records for personal use or for parties other that your insurance company or other physicians involved with your care may be subject to a fee and, if printed records are requested, there may be an additional fee for supplies and postage. Ask your support specialist for additional information.
I have reviewed, understand and accept ONCALL HEALTHCARE'S MEDICAL RECORDS RELEASE CONSENT.
Your Signature
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