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Request Medical Records – Clinics

Request Medical Records – Clinics

I hereby authorize Knox Clinic to release the following information from the medical records of:

Patient Information

First Name: *

Middle Initial:

Last Name: *

Name at Time of Treatment (if different than above):

Date of Birth: *

Phone: *

E-mail: *

Street Address:

City:

State:

Zip:

I am requesting my records from:

Facility Name: *

Facility E-mail:

Address:

City:

State:

Zip:

Facility Fax:

What records do you want to receive or have disclosed to the recipient noted? (Check appropriate boxes below):

Date(s) of Service:

Through:

Discharge Summary Consultation(s) Pathology Reports Lab Reports History and Physical

Operative Note(s) Imaging/X-Ray Reports Entire Record

lmaging/X-Ray Films Fetal Heart Monitor Strips

Other (specify)

If it exists, the following Sensitive Information can be disclosed:

Alcohol Abuse Drug Abuse Communicable diseases, including HIV status Genetic Testing

Psychiatric/Behavioral Diagnoses

How would you like your records delivered?

Paper Electronic I will pick up in person Mail to address below

If mailing, where do you want the information sent? (Fill in boxes below):

Please provide my records to:

Myself Personal Representative (indicated below) Other Third Party (indicated below)

Recipient Name:

Recipient Phone:

Recipient Fax:

Recipient Mailing Address:

Recipient E-mail (if applicable):

Please print your name and sign below:

Name of Patient or Personal Representative:

Relationship:

eSign of Patient or Legal Representative: *

eSign Can not be empty

Clear Signature

Date of Signature:

Upload a copy of identity(Passport, Driving License) *

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by Galesburg Cottage Hospital

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Preferred Date

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Additional Message

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