Inova Information

Patient Name ___________________________________________________

Medical Record Number _______________________________________

Social Security# (Optional) _______________________________________

Patient Date of Birth __________________________________________

Dates of Service _________________________________________________

Contact Phone Number ________________________________________

Street Address

City

State

Zip Code

I authorize

To release or disclose the following information to:

Physician Phone # _______________________ (required if records are to be faxed)

____________________________________________________________

Fax # ____________________________________

Name of person or entity to receive information

For physician or patient only

Street Address

City

State

Zip Code

Information to be released/disclosed:

Emergency Room Record

Psychiatric Admit Note

EKG/EEG

Face Sheet

Psychiatric Evaluation

Substance Abuse Records

Discharge Summary

Progress Notes

Plan of Care (Home Health)

History & Physical

Physician Orders

Complete Health Record

Consultation

Radiology Reports

Record Abstract

Operative Report

Radiology Films/CD

Billing Information

Pathology Report

Laboratory Reports

Other _________________

Purpose:

Medical Follow-Up

Individual use

Insurance

Attorney

Disability

Other__________________

Patient advised of charges:

Yes No N/A

Please mail the records

Fax to the number above

I will pick up the records

I wish to review the records

Note: You will need to make an appointment for the review

Signature of Patient or Representative

Date (Authorization will expire six months after date signed)

Print Name of Personal Representative (If applicable)

Relationship to Patient

INOVA HEALTH SYSTEM

PATIENT LABEL

AUTHORIZATION TO RELEASE/DISCLOSE

PROTECTED HEALTH INFORMATION