RELEASE OF MEDICAL RECORDS

Please release my medical records from:

Address:

Phone:

Fax:

To: Multnomah Family Care Center, PC

7689 SW Capitol Highway

Portland, OR 97219

Fax (503) 445-4464

Patient Name:

Date of Birth:   ____ / ____ / _____

Contact Number:    ( _____ ) ______ – _______

Mailing Address:

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

Date _____/_____/______

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.