I authorize electronic transmission (fax) of my medical records. Records may be provided in electronic form on a secure disk. Paper records are available upon request.
I understand that if the person(s) and or organizations(s) listed above are not health care providers, health plans or health care clearinghouses, who must follow the federal privacy standard, the health information disclosed as a result of this authorization may no longer be protected by the federal privacy standards, and my health information may be re-disclosed without obtaining my authorization. This authorization will automatically expire one year from date of signature. I understand that I may revoke this authorization at any time by notifying the providing organization in writing, but if I do, it will not have any effect on the actions they took before they received the revocation. Any refusal to sign this form will not affect my ability to obtain treatment, payment or my eligibility for benefits. I may request to inspect or copy the health information to be used or disclosed. This release is not valid if it does not contain the patient signature.
There may be a delay in processing your request if the information provided on this form does not match with the electronic record. Release of Information staff may contact you at the e-mail, address or phone number listed to request verification before processing.
Legal documentation is required supporting his/her authority to act on a patient’s behalf. Photo identification is requested for all hand carry release of information requests. Facsimile reproductions of the signature are acceptable. Our practice may charge a fee for the costs of copying, mailing, labor and supplies associated with your request. If additional information is needed please contact McFarland Clinic Release of Information.