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Patient Name (Required.)

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Patient Date of Birth (Required.)

Date

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Email (Required.)

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Address (Required.)

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Phone Number (Required.)

Medical Records
Define your record request below.
Note radiology images need to be requested from the Fairbanks Imaging & Breast Center by clicking here

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Dates of Treatment (Required.)

And/Or

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Describe Records Needed (Required.)

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Purpose (Required.)

Recipient Contact Information

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Facility/Recipient Name (Required.)

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Record Format & Delivery (Required.)

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Recipient email address or fax number (Required.)

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Additional Recipient Contact Information (Required.)

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**REQUIRED** Photo ID (Required.)

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RELEASE AUTHORIZATION
I understand that 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, Behavioral Health Care/ Psychiatric Care, treatment of alcohol and/or drug abuse and genetic testing; my signature authorizes release of any such information.

I may refuse to sign this authorization form. I understand that Foundation Health Partners will not condition or deny treatment on my signing this authorization. I understand that I may revoke this authorization at any time, except to the extent that action based on this authorization has already been taken. Foundation Health Partners’ Notice of Privacy Practices explains the process for revocation, which includes a request in writing.

Unless I revoke this authorization earlier, it will expire 6 months from the date signed.

I understand that, if this information is disclosed to a third party, the information may no longer be protected by state, federal regulations and may be re-disclosed by the person or organization that receives the information.

I release Foundation Health Partners, its employees and agents, medical staff members, and business associates from any legal responsibility or liability for the disclosure of the above information to the extent indicated and authorized herein.

Typing my full name and date in the boxes below serves as my signature and authorization to release my information.

Signature of patient or legal representative: (Required.)

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Relationship to Patient (Required.)

( Privacy & Cookie Notice

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