Request for Release of Medical Records

Date & Time Field

Patient Consent & Release Form

Note: Please allow 24-48 business hours for processing. If you do not recieve your documents within this timeframe, please call our offices at 704-802-9625 and ask to speak with someone in the Compliance Department.

Note: Medical Records will only be released directly to the client or the client's legal representative (parent or legal guardian). Records will not be released if requested by family members, significant others, legal representation, etc.

Notice to Attorneys / Legal Representatives / Third-Parties:
This form is for patient use only. Law firms & third-parties may not complete or sign this form on behalf of a patient. Third-party record requests must be submitted via fax (888-502-5390) with a valid HIPAA-compliant Authorization for Release of Medical Records signed by the patient.

PATIENT & RECORD INFORMATION

Patient Name (First & Last)

Patient Birthdate

Reason for Release

Release Records to:

Release of:

	All Records
	Specific Records / Date Range

Date Range and/or Record(s) description:

Send Records via:

	Fax
	Email

Fax Number

Email Address

AUTHORIZATIONS & CONSENT

I authorize Helms Home Care to furnish the individual / entity / organization below with all medical records and information they may request, as related to services and care provided to me during the time frame indicated.

I Consent

I understand this consent is subject to revocation by the undersigned at any time except to the extent that action has been taken in reliance hereon, and if not earlier revoked, it shall terminate six (6) months from the date of consent without express revocation.

I Consent

I consent to the release of any and all records including records that may contain alcohol use and/or drug abuse and/or psychiatric diagnosis under the same consideration as outlined above. I understand that such information cannot be released without my specific consent, except in accordance with a court order.

I Consent

I further understand that I have a right to receive a copy of this authorization upon request.

I Consent

I would like a copy of this Medical Release form emailed to me:

	No
	Yes

Email Address to send copy:

I hereby consent to the release of any and all records that may contain ALCOHOL / DRUG ABUSE / AIDS / PSYCHIATRIC DIAGNOSES under the same consideration as above. I understand that such information cannot be released without my specific consent, except under a Court Order.

Signature of Client or Legal Representative

	I am the patient, signing on behalf of myself
	I am a Parent, Legal Guardian, or Legal Representative signing on behalf of the patient

Name of Signor

Relationship to Patient

Mailing Address

Phone

parentPageID

PDFFILENAME

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FormID

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