Medical Records Release

Authorization to Obtain Health Information

Fill out this form to authorize obtaining health information from another healthcare provider/organization to: Cirrus Medical Network, LLC (CirrusMED) 10627 Professional Circle Reno, NV 89521

Today's Date

Patient Name*

First Last

Address of Patient

Street Address Address Line 2 City State ZIP Code

Date of Birth

Name of Healthcare Provider/Organization to Obtain Protected Health Information From:

Address of Healthcare Provider

Street Address Address Line 2 City State ZIP Code

Phone

Healthcare Provider Phone # (if known)

FAX

Healthcare Provider FAX # (if known)

Information to be obtained:

(select all that apply)

For the following dates:

(specify dates from: dd/mm/yyyy to: dd/mm/yyyy)

Copies of medical records pertaining to diagnosis and/or treatment of psychiatric, psychological condition and/or drug abuse may be released to the recipient as noted in this form? Yes or No?

Yes
No
not applicable

Copies of medical records, including information of the diagnosis and/or treatment for AIDS/HIV (including testing may be released to the recipient as noted above? Yes or No?

Yes
No
not applicable

Purpose for need of disclosure:

For further medical care
Insurance eligibility/benefits
Legal investigation of action
Personal
Changing physicians
Other (leave in comments)

(Select all that apply)

Your Rights with Respect to This Authorization:

I understand my rights and terms as described below.

I understand that if the person(s) and/or organization(s) listed above are not health care providers, health plans, or health care clearinghouses, who must follow the federal privacy standards, the health information disclosed as a result of this authorization may no longer be protected by the federal privacy standards and my health information may be redisclosed without obtaining my authorization.

Right to receive a copy of this authorization - I understand that if I agree to sign this authorization, which I am not required to do, I must be provided with a signed copy of the form.

Right to refuse to sign this authorization - I understand that I am under no obligation to sign this form and that the person(s) and/or organization(s) listed above who I am authorizing to use and/or disclose my information may not condition treatment or payment, on my decision to sign this authorization.

Right to withdraw this authorization - I understand written notification is necessary to cancel this authorization. To obtain information on how to withdraw my authorization or receive a copy of my withdrawal, I may contact the privacy director at 702-690-9711 or support@cirrusmed.com. I am aware that the revocation will not apply to the information that has already been released in response to this authorization.

Expiraton Date

This authorization is good until the specified date. If I fail to specify and expiration date or event, this authorization will expire 90 days from the date on which it was signed.

Comments

Consent*

I have had an opportunity to review and understand the content of this authorization form. By signing this authorization, I am confirming that it accurately reflects my wishes

Is person signing this form someone other than the patient?*

No
Yes

Signature of Patient:

Date of Signature

Patient is:

Minor
Incompetent
Disabled
Deceased

(If signed by person other than patient, state relationship and authority to do so.)

Legal Authority

Custodial Parent
Legal Guardian
Executor of Estate of Deceased
Power of Attorney For Healthcare
Authorized Legal Representative

Signature of Witness:

Date of signature

Medical Records Release Form

Authorization to Obtain Health Information