MyMedicalHistoryOnline.com

Medical record and history organization for safer patient care.™

AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS

I hereby authorize that the medical record information regarding:

Patient Name: Last                                                      First                                            M.I.

Street Address:                                                                         City                                               State          

Phone:                                     Date of Birth:

Social Security #:                                 Medical Record # (if known):

be forwarded from:

Institution or Medical Provider:

Street Address                                                                           City                                              State

Fax Records to Dr. Erik Kulstad, MD, at the following fax number:  (888) 481-4756

This information is to be used to further streamline and organize my medical care, and enable me to provide my caregivers with the most complete, and up-to-date information possible. 

Information that I would like to organize includes data from within the last 18 months, including all checked items below:

X-ray results CT scan readings MRI readings Ultrasound interpretations Recent laboratory test results Blood tests Serum chemistries

12-lead EKG tracing Urinalyses Major operative reports Holter monitor summaries Pulmonary function tests Diagnostic procedure reports Recent hospital discharge summaries Other

If the information to be disclosed contains any of the types of records or information listed below, additional laws relating to the use and disclosure of the information may apply. I understand and agree that this information will be disclosed only if I place my INITIALS in the applicable space next to the type of information.

_____ HIV/AIDS information

_____ Mental health information

_____ Genetic testing information

_____ Drug/alcohol diagnosis, treatment, or referral information

AUTHORIZATION TO USE AND DISCLOSE PROTECTED HEALTH INFORMATION

ALL SECTIONS OF THE AUTHORIZATION MUST BE COMPLETED OR THE AUTHORIZATION WILL NOT BE ACCEPTED.

You may revoke this authorization in writing at any time. If you revoke your authorization, the information described above may no longer be used or disclosed for the purposes described in this written authorization. Any uses or disclosures already made with your permission cannot be undone.

I have read this authorization and I understand it.

Patient Signature:   Date:

Authorization if patient is unable to sign:

Relationship to patient if unable to sign: