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Authorization to Release Medical Records

Complete the patient information and indicate why the information is needed and which records may be released or accessed.

Name of Patient(Required)

Date(s) of Service

Enter the date or date range for the records, if known.

Date of Birth(Required)

Social Security Number

Optional. Please provide only if specifically requested by the office.

I, the undersigned, authorize the release of, or request access to the information specified below from the medical record(s) of the above named patient.

Patient information is needed for(Required)

Continuing Medical Care

Military

Social Security/Disability

Insurance

Personal Use

Legal Purposes

School

Other

Other purpose (please specify)

Information to be released or accessed(Required)

History & Physical

Consultation Report

Emergency Room Record

Operative Reports

Discharge/Death Summary

Face Sheet

Lab/Path Reports

X-Ray Reports/Images

Other: Any and all records

Release of Information – TO

The above information may be released (specify name or title of the individual or the name of the organization to which records are to be released and the appropriate address):

Dr. Jasmine Scott, DC
Phone: 985-233-4328
429 W. Airline Hwy., Ste. F, Laplace, LA 70068

Records requested – FROM

Dr. Jasmine Scott, D.C.
Phone: (985) 233-4328
501 Rue de Sante, Ste. 11, Laplace, LA 70068

Confidentiality and Authorization Terms

I understand that my records are confidential and cannot be disclosed without my written authorization, except when otherwise permitted by law. Information used or disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and no longer protected. I understand that the specified information to be released may include but is not limited to history, diagnoses, and/or treatment of drug or alcohol abuse, mental illness, or communicable disease, including HIV and AIDS.

I understand that I may revoke this authorization in writing at any time except to the extent that action has been taken in reliance upon the authorization.

The authorization will expire one year from the date of my signature, unless I revoke the authorization prior to that time.

Printed Name of Patient or Legally Authorized Representative(Required)

Relationship to Patient(Required)

Enter Self if the patient is signing, or state your representative relationship.

Date of Signature(Required)

Authorization Acknowledgment(Required)

I have read and understand the authorization and consent to the release or access of the records selected above.

Signature – Patient or Legally Authorized Representative(Required)

Sign using your finger, mouse, or trackpad.

Authorization to Release Medical Records