Harvard Vanguard Records Form – Fill Out and Use This PDF

Incoming Records

Patient Instructions and Information:

•Please complete this form and mail to former healthcare provider to request a copy of your medical record.

Please be aware that medical record copy fees may apply and contacting your former healthcare provider for specific medical record processing details is recommended.

Authorization to Obtain Medical Records

Patient’s Name: ___________________________________________	Date of Birth: ____________________________
(Please Print)

Address: _____________________________________________________________________________________________

StreetCity State ZipTelephone No.

I do hereby, authorize __________________________________________________________________________________

Name of Physician , Facility or Person

Located at __________________________________________________________________________________________

Street

City

State

Zip

to release protected health information, contained in the medical record of the above-named patient to the following HVMA clinician:

Dr. _________________________________

Harvard Vanguard Medical Associates

_______________________________________

Street

_______________________________________

CityState Zip

_____________________________________

Special Authorization for Release of Statutorily Protected Information from the Medical Record

I understand the following categories of information may be in the medical record and SHOULD NOT be released unless specifically authorized as indicated by my checking and initialing each appropriate category.

____ Abortion	_____ Behavioral/Mental Health		_____ HIV/AIDS Results/Treatment
____ Alcohol/Drug Abuse	_____ Domestic Violence		_____Child/Elder/Disabled Abuse
____ Rape/Sexual Assault	_____ Genetic Testing		_____Sexually Transmitted Diseases
Information to be released:
Dates of Treatment to be Released: _________ to ___________		Laboratory Result		X-ray (Reports Only)
Office Notes: _____________________________		Immunization Record		Complete Record
Specify Clinician(s)

Other: ________________________________________________________________________________________

Purpose of Release:

Medical Care

Other: _______________________________________

I understand that once this health information is disclosed, the releasing facility cannot guarantee that the recipient will not redisclose my health information to a third party. Such third party may not be required to abide by this Authorization or applicable federal and state law governing the use and disclosure of my health information.

I understand that I may refuse to sign or may revoke this Authorization in writing at any time and for any reason and that such refusal or revocation will not affect the commencement, continuation or quality of my treatment. I understand that this authorization will expire 90 days from the date of said authorization unless I provide a written notice of revocation to the releasing facility noted above.

__________________________________________________	_____________________________________
Signature of Patient or Authorized Representative	Date
_________________________________________________	______________________________________

Printed Name of Patient or Authorized Representative	Relationship to Patient