Peoria Foot and Ankle Medical Release Request Form

Please enable JavaScript in your browser to complete this form.
PATIENT INFORMATION
Patient Address

Send Records To: I hereby request that my medical records be released to:

Please allow 7-10 business days for your request to be complete. Please call our office for more urgent requests.
Address Records Will Be Sent To:
Note: If you are requesting the records to be sent to yourself, we will be using the current patient address on file for you.
Select Information to Disclose
Reason For Request (Check all that apply)

Authorization of Patient (or Legal Representative)

Please Read and Sign:

I authorize Peoria Foot and Ankle to forward a copy of the selected patient medical records to use or disclose Protected Health Information (PHI) for the purpose(s) selected above.

I understand the information in this health record may include information relating to sexually transmitted disease, acquired immunodeficiency syndrome (AIDS) or human immunodeficiency virus (HIV). It may also include information about behavioral or mental health services and treatment for alchohol and drug abuse.

I understnad that I have the right to revoke this authorization at any time and if I revoke this authorization or have questions about any disclosure of my PHI, I must do so in writing and present my written revocation to the HIPAA Privacy Officer for the facility of the original medical records.

I understand that the revocation will not apply to my insurance company when the law provides my insurer with the right to contest a claim under my policy. Unless otherwise revoked, this authorization will expire in ninety (90) days.

I understand that authorizing the disclosure of this PHI is voluntary and I need not sign this form in order to assure treatment.

I understand that I may inspect or copy the information to be used or disclosed, as provided  in CFR164.524.

I understand that any disclosure of information carries with it the potential for an unauthorized red-disclosure and the information may not be protected by federal confidentiality rules. If I have questions about disclosure of my health information, I can contact the HIPAA Privacy Officer at the facility of origin of the medical record.