PHVC Medical Records Release. Authorization to use or disclose protected health information

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Patient Name (Required.)

First

Last

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Patient Date of Birth (Required.)

Please enter the patient's date of birth

Date

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Email (Required.)

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Address (Required.)

Address

City/Town

State

ZIP/Postal Code

Country

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Phone Number (Required.)

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Leave a Message (Required.)

Yes

Medical Records
Define your record request below

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Date(s) of Treatment (Required.)

All dates of treatment

Specific dates of treatment (provide dates below)

Please list your dates here

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Information Requested: If you are seeking Laboratory reports, please make your request to Fairbanks Memorial Hospital by clicking here. To request radiology reports click here.To request records from Tanana Valley Clinic click here. (Required.)

All Porter Heart Records

Office Visits

Cardiovascular Reports

Comments (please specify below)

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Purpose (Required.)

Personal

Continuation of Care

Other (please specify)

Information to be sent to: please complete the following. If you are the recipient of the records, input your contact information.

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Facility/Person Name (Required.)

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Record Format & Delivery (Required.)

Mailed paper copy

Email (PDF) copy

Fax

Patient Portal

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Fax Number (REQUIRED if records are to be sent to another health care facility or organization): (Required.)

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Recipient's Contact Information (Required.)

Address

City/Town

State/Province

ZIP/Postal Code

Country

Email Address

Phone Number

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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.)

Full Name of Requester

Today's date

Relationship to Patient

PHVC Medical Records Release. Authorization to use or disclose protected health information

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* Patient Name (Required.)

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* Patient Date of Birth (Required.)

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* Email (Required.)

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* Address (Required.)

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* Phone Number (Required.)

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* Leave a Message (Required.)

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* Date(s) of Treatment (Required.)

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* Information Requested: If you are seeking Laboratory reports, please make your request to Fairbanks Memorial Hospital by clicking here. To request radiology reports click here.To request records from Tanana Valley Clinic click here. (Required.)

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* Purpose (Required.)

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* Facility/Person Name (Required.)

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* Record Format & Delivery (Required.)

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* Fax Number (REQUIRED if records are to be sent to another health care facility or organization): (Required.)

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* Recipient's Contact Information (Required.)

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* **REQUIRED** Photo ID (Required.)

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Patient Name (Required.)

Patient Date of Birth (Required.)

Email (Required.)

Address (Required.)

Phone Number (Required.)

Leave a Message (Required.)

Date(s) of Treatment (Required.)

Information Requested: If you are seeking Laboratory reports, please make your request to Fairbanks Memorial Hospital by clicking here. To request radiology reports click here.To request records from Tanana Valley Clinic click here. (Required.)

Purpose (Required.)

Facility/Person Name (Required.)

Record Format & Delivery (Required.)

Fax Number (REQUIRED if records are to be sent to another health care facility or organization): (Required.)

Recipient's Contact Information (Required.)

REQUIRED Photo ID (Required.)