q Waugh Chapel Family Medicine

Authorization for Release of Information

2401 Brandermill Boulevard, Suite 250

Gambrills, MD 21054

Office: 410-721-1507 Fax: 410-721-1510

Patient Information:

Print name:_______________________________________________________ Date of Birth: ______________

Address: ___________________________________________________________________________________

SS#: ______________________________________ Maiden or prior name:______________________________

Please release my healthcare information from: Waugh Chapel Family Medicine 2401 Brandermill Blvd, Ste 250 Gambrills, MD 21054 Phone #: 410-721-1507, Fax: 410-721-1510

Please send my healthcare information to: Name of Facility/Provider: ____________________________ Address: _________________________________________ City/State/Zip ______________________________________ Phone Number: ____________________________________

Information to be released (please check the appropriate box):

q The most recent 2 years of pertinent information (chart notes, labs, ultrasounds and special tests)

q All medical records

q Specific information (please specify)

Purpose for which disclosure is being made (please check appropriate box if relevant):

q Sharing with other health care providers	q Personal use
q Legal investigation	q I am transferring my care to a new health care provider
q Other: ___

________________________________________________________________________________________________ 

Patient Authorization

I understand that the information in my health record may include information relating to sexually transmitted disease, acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV). Waugh Chapel Family Medicine is specifically authorized to release all health care information relating to such diagnoses, testing or treatment.

My Rights

I understand that I do not have to sign this authorization in order to obtain health care benefits (treatment, payment or enrollment). I may revoke this authorization in writing. (To view the process for revoking this authorization, please read our Privacy Notice to patients on-line, or as posted in our facility.) I understand that once the health information I have authorized to be disclosed reaches the noted recipient, that person or organization may re-disclose it, at which time it may no longer be protected under Privacy laws.

Fees for Copying Medical Records

Waugh Chapel Family Medicine will continue to provide one complimentary copy of a patient's medical record to another health care provider (exceptions, of course, for emergency situations)

Our charges to release records to a patient or relative are as follows (2008 fees): $22.18 base fee for preparing records and 73 cents per photocopied page. In addition the actual cost of shipping and handling charges will apply. This fee must be paid before your records can be released.

I understand that I may be charged at the rates shown above for the copies of the records I have requested and for postage, if needed. I agree to pay the total charges upon receipt of the copies.

Signature: ____________________________________________________ Date: _____________________________

(Patient, Guardian*, Authorized Representative* - * Please provide documents to prove authority to sign on behalf of the patient)

THIS AUTHORIZATION WILL EXPIRE 90 DAYS FROM THE DATE SIGNED

Up dated: 10/15/2008