Form For Release of Information

Patient Information

Today's Date*

MM slash DD slash YYYY

Patient Name*

First Name Middle Initial Last Name

Patient's Date of Birth*

MM slash DD slash YYYY

Email*

The purpose or need for this disclosure is:*

Coordination of Care

Disability Application

Other

The purpose or need for this disclosure is:*

Responsible Party*

If patient is a minor or has a legal representative or guardian, additional information is needed.

Patient

Guardian or Legal Representative

Is the patient is 14 years or older?*

Please note that if the patient is 14 year or older a signed release by the patient is required to share information with the patient’s parents or legal guardians.

Yes

Responsible Party Info

Responsible Party*

First Last

Responsible Party Email*

Authorization For Release Of Protected Health Information

From Ravi Kant, MD, P.C.

Please release my medical information to the following:*

Please note that if the patient is 14 year or older a signed release by the patient is required to share information with the patient’s parents or legal guardians.

PCP

Family Member

Therapist

Other

Release to*

Name of provider, facility, or family member where records are being released to.

First Last

Address*

Street Address Address Line 2 City State ZIP Code

Phone*

Fax

Would you like to share your medical information with anyone else?

Yes

Please release my medical information to the following:*

Please note that if the patient is 14 year or older a signed release by the patient is required to share information with the patient’s parents or legal guardians.

PCP

Family Member

Therapist

Other

Release to*

Name of provider, facility, or family member where records are being released to.

First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Phone*

Fax

Would you like to share your medical information with anyone else?

Yes

Please release my medical information to the following:*

Please note that if the patient is 14 year or older a signed release by the patient is required to share information with the patient’s parents or legal guardians.

PCP

Family Member

Therapist

Other

Release to*

Name of provider, facility, or family member where records are being released to.

First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Phone*

Fax

I authorize the entities named above to share the health related information related to my care.*

Initial here:

Records To Be Released*

I understand that the specific types of records to be released (identify all records or all that apply) are:

All records including Psychiatric/psychological evaluation

Laboratory reports & tests

Physician notes only

Insurance claims and payments only (including Medicare and Medicaid)

Other

Specify other records:*

**Mental or behavioral health, substance abuse, and HIV-related information contained in the parts of the records indicated above will be released through this authorization unless otherwise indicated.**

DO NOT RELEASE:

Mental/Behavioral Health (Psychiatric)

HIV-Related

Substance Abuse (Drug and Alcohol)

I certify that this data is true, correct & accurate. I understand that payment of this claim will be from federal & state funds. Any false claims, documents, or concealment of material facts may be prosecuted under applicable laws. Under penalty of perjury, I herewith affirm that my electronic signature, and all future electronic signatures, were signed by myself with full knowledge and consent and am legally bound to these terms and conditions.

Patient Signature*

I consent to and authorize to disclose my protected health information relating to my identity, diagnoses, prognosis, and/or treatment. These records may include information related to medical conditions, tests, mental or behavioral health, substance abuse (drug and alcohol), and HIV-related. These records are called protected health information and are protected by federal and/or state law.

I understand that this authorization is revocable upon my written request and that this consent will remain in force unless revocation from the patient or legal guardian is received. I also understand that any revocation of this authorization must be in writing and sent or delivered to my health care provider’s office. I also understand that my decision to revoke this authorization may result in my insurance company not being able to pay for my medical care and I will be liable for payment for the services rendered.

Minor Patient Signature

Please note that if the patient is 14 year or older a signed release by the patient is required to share information with the patient’s parents or legal guardians.

Responsible Party Signature*

Phone

This field is for validation purposes and should be left unchanged.

Form For Release of Information

Patient Information

Responsible Party Info

Authorization For Release Of Protected Health Information

From Ravi Kant, MD, P.C.

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