This form must be filled out in its entirety before we can comply with record requests. New York State law requires all patients requesting the release of their medical records to give permission in writing. Permission to release HIV related records to any person, company or institution must also be specifically requested in writing.

Name*

_________________________________________________

Date of Birth *

_________________________________________________
ex: mm/dd/yyyy

Are you transferring your care out of our office?
Yes
No

By completing this form, I authorize the Spring Ob/Gyn to release a copy of my medical records to:

 

 

Please provide record via:

___ Regular Mail
___Password protected PDF E-Mail
___Fax
___Picked up in person at the office

 

Reason for Request

If you only require specific reports or results, please specify which ones below:

 

 

 

Include HIV related information?
Yes
No

Notice

Spring Ob/Gyn PC and many other organizations and individuals such as physicians, hospitals and health plans are required by law to keep your PHI confidential. If you have authorized the disclosure of your PHI to someone who is not legally required to keep it confidential, it may no longer be protected by state or federal confidentiality laws.

MY RIGHTS

I understand this authorization is voluntary. Treatment, payment enrollment or eligibility for benefits may not be conditioned on signing this authorization except if the authorizations is for 1) conducting research-related treatment, 2) to obtain information in connection with eligibility or enrollment in health plan, 3) to determine an entity?s obligation to pay claim, 4) to create PHI to provide to a third party I may revoke this authorization at any time, provided that I do so in writing and submit it to:

Spring Ob/Gyn
135 Spring Street, 2nd Floor
New York, NY 10012

Patient / Representative Signature: *

_________________________________________________

Relationship to Patient: *

_________________________________________________

Date of Signature *

_________________________________________________

All medical records requests will take 3-5 business days from the date the signed request is received.

Outgoing Records Release