Medical Record Release - The Toledo Clinic

Patient Information

Patient First Name(Required)

Patient Last Name(Required)

Last 4 numbers of Social Security #

Maiden or Other Name

Patient Address(Required)

City(Required)

State(Required)

Zip Code(Required)

Date of Birth(Required)

Phone Number(Required)

Cell Number

Work number

Email

Release Information From

I hereby authorize the below physician from The Toledo Clinic to release my medical records information.

Provider Name/Specialty:(Required)

Address

City

Zip Code

Phone

Release Information To

Release information to:(Required)

Name of New Provider/Facility

Self

Provider Name/ Facility(Required)

Attention

Address(Required)

Phone(Required)

City(Required)

State(Required)

Zip(Required)

Fax(Required)

City(Required)

State(Required)

Zip(Required)

Fax

Patient Email Address

Specific dates of service to be released

Records to be released

Physician Office Pertinent Transfer Package (standard two years of information)

Progress Notes

Laboratory / Path Report(s)

Radiology Report(s)

Radiology Disk and Report(s)

Immunization Record

Other

Please be specific, include dates or testing needed

By signing I understand that the information in my health records may include information relating to sexually transmitted diseases, acquire immune deficiency syndrome (AIDS), or human immune deficiency virus (HIV). It may also include information about behavior or mental health services, and treatment for alcohol and drug abuse.

This consent is valid for 90 days from the date of signature unless revoked by me in writing before release of information as designed above. A copy of this authorization, including the following disclosure statement, will be furnished to whom the information is to be released. This information has been disclosed to you from confidential records from disclosure by state law. You shall make no further disclosure of this information without specific written and informed release of the individual to whom it pertains, or as otherwise permitted by state law.

If you are the legally recognized representative of the patient you must provide supporting documentation.

This agreement has been signed electronically.

Signing Authority(Required)

Patient

Patient Representative

Signature(Required)

Today's Date(Required)