Authorization for ReviveMD to release Protected Health Information to outside party

Patient Information:

Patient First Name

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Patient Last Name

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Date of Birth

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Any other Previous Names

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Patient Address

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Phone #

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City

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State

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Zip

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I hereby authorize Prima CARE to RELEASE my medical record information to:

Name/Facility

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Attention

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Address

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Phone #

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City

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State

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Zip

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Fax #

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Purpose of Request

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If Other

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If Transfer from Practice, What is the reason?

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Specific Records/Report(s) to be released:

Please do not prepay. You will be invoiced for your selection by our vendor.

Send a 2-year abstract of my records

Other – be specific, include dates and MD’s under comments.

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COPY FEE: Pursuant to HIPAA 45 CFR, 164.524, we reserve the right to charge a reasonable cost-based fee for producing and mailing the copies At no time will the cost-based fees exceed Massachusetts law (MGL Chapter 111; Section 70)

Restricted authorization to release Protected Health Information:

IMPORTANT – It is extremely important that you select either you “DO” or “DO NOT” for each item contained in this section. Please do not skip any line item as it could delay the fulfillment of your request.

want Mental/Behavior Health or Disability Services Provider Documentation * released

Please select an option.

want HIV/AIDS Screening Test Results released

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want information about Alcohol and/or Substance Abuse Treatment released.

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want Genetic Testing/Test Results ** released.

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want Confidential Communications with a Social Worker released

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want information about Rape/Sexual Assault Victim’s Counseling released.

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want Child/Elder Abuse or Neglect & Abuse of an Adult with a Disability released.

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want information about Sexually Transmitted Disease (STD’s) released.

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want information about Abortion released.

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* This Authorization is not valid for use or disclosure of psychotherapy notes.
** The term “genetic tests” means only those tests which determine your future chances of developing a disease, not test done to diagnose a current condition

Please sign your name in the area below

By submitting your signature, the parties agree that this agreement may be electronically signed. The parties agree that the electronic signatures appearing on this agreement are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

Date

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Signature of Personal Representative

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Relationship to patient or authority to act for patient

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Date

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Authorization for ReviveMD to release Protected Health Information to outside party

Patient Information:

Patient Information:

I hereby authorize Prima CARE to RELEASE my medical record information to:

I hereby authorize Prima CARE to RELEASE my medical record information to:

Specific Records/Report(s) to be released:

Specific Records/Report(s) to be released:

***Please do not prepay. You will be invoiced for your selection by our vendor.***

COPY FEE: Pursuant to HIPAA 45 CFR, 164.524, we reserve the right to charge a reasonable cost-based fee for producing and mailing the copies At no time will the cost-based fees exceed Massachusetts law (MGL Chapter 111; Section 70)

Restricted authorization to release Protected Health Information:

Restricted authorization to release Protected Health Information:

IMPORTANT – It is extremely important that you select either you “DO” or “DO NOT” for each item contained in this section. Please do not skip any line item as it could delay the fulfillment of your request.

Please do not prepay. You will be invoiced for your selection by our vendor.