RELEASE OF MEDICAL RECORDS
Please release my medical records from:
To: Multnomah Family Care Center, PC
7689 SW Capitol Highway
Portland, OR 97219
Fax (503) 445-4464
Date of Birth: ____ / ____ / _____
Contact Number: ( _____ ) ______ – _______
I am requesting a copy of my HIPPA protected information be mailed or faxed to Multnomah Family Care Center, PC for:
(Please Initial) _____ Transferring Care
_____ Coordination of Care
In addition to the standard HIPPA protected medical information, please include all records related to:
(Please Initial) _____ Mental Health Records
_____ HIV Tests
_____ Alcohol / Drug Diagnosis, Treatment, and/or Referrals
I understand that I do not have to sign this authorization to receive treatment.
I understand that I can revoke this authorization at any time.
I understand that this authorization to release my HIPPA protected information does not cancel any rights I have under State or Federal laws.
This authorization is valid for 90 days after request is signed.
Signature of Patient or Legal Guardian
Please print this page and fax to the office you are requesting to transfer your records from or bring with you to your first visit. We are working on a way to have this form submitted automatically and will update as we can.