Medical Records Release Medical Records Release Form To request medical records FROM another provider or facility TO Cirrus Medical Network (CirrusMED) fill out this form. Authorization to Obtain Health InformationFill out this form to authorize obtaining health information from another healthcare provider/organization to: Cirrus Medical Network, LLC (CirrusMED) 10627 Professional Circle Reno, NV 89521Today's Date MM slash DD slash YYYY Patient Name* First Last Address of Patient Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Date of Birth MM slash DD slash YYYY Name of Healthcare Provider/Organization to Obtain Protected Health Information From: Address of Healthcare Provider Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code PhoneHealthcare Provider Phone # (if known)FAXHealthcare Provider FAX # (if known)Information to be obtained: ENTIRE RECORD Discharge Summary History & Physical X-Ray / Diagnostic Imaging Reports Consultations Physician Progress Notes List of Allergies Physician Orders Lab Results Medication Lists Problem List Immunizations Records (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 MM slash DD slash YYYY 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. CommentsConsent* 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 wishesIs person signing this form someone other than the patient?* No Yes Signature of Patient: Reset signature Signature locked. Reset to sign again Date of Signature MM slash DD slash YYYY 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: Reset signature Signature locked. Reset to sign again Date of signature MM slash DD slash YYYY Δ
