Medical Records Release

First Name

Last Name

Date of Birth

Email Address

Street Address

City State Zip

Phone

Your Signature

Today's Date required

I hereby authorize BFRIN to Release/Request all Private Health Information-PHI contained in my medical records without expiration for medical purposes - including, but not limited to: Lab Reports X-Ray Reports Sexual Abuse Information Sexually Transmitted Diseases (STD's) Drug and Alcohol Abuse Information Child Abuse and Neglect Reports Psychiatric Information HIV/Aids Report and Other relevant PHI. While specific confidential PHI will not be included, the information authorized for release may make reference to confidential findings for health related reasons. I understand that I may revoke this authorization in writing at any time except to the extent that the release has been made prior to my revocation in reliance on this authorization and that such release shall not constitute a breach of my right to confidentiality. Unless I otherwise revoke this authorization in writing, it is valid indefinitely/lifetime. Treatment of payment may not be conditioned on obtaining authorization for release of PHI. I understand that by releasing PHI, my PHI might be subject to re-disclosure. I hereby release BFRIN from any legal responsibility or liability regarding PHI discussed in this Release. I have read this authorization and fully agree to its contents.

Premyèman, tcheke kaz ki sou bò GÒCH la pou w ka Soumèt.

Medical Records Release

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