Medical Record Release Form

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

If you would like to authorize Brooklyn Acupuncture Project release your records, please fill out the form below.

Your full name: *

Your full address *

The full name and mailing address of the person or organization to whom Brooklyn Acupuncture Project has your authorization to release records to: *

The email address to which Brooklyn Acupuncture Project has your authorization to send your records to:

What records do you authorize Brooklyn Acupuncture Project to release? Check the boxes for all types of information you authorize the release of: *

In accordance with New York State Law and HIPAA medical records will exclude any information about 1.) alcohol/drug treatment, 2.) mental health information and 3.) HIV related information unless explicit permission is granted by the patient. Please indicate all records you authorize Brooklyn Acupuncture Project to release by checking the corresponding boxes below.

All medical records (this does not include mental health, drug treatment, or HIV information unless boxes or checked below.

Alcohol/drug treatment records

Mental health information

HIV related information

Required

Expiration of authorization

I understand that authorization for Brooklyn Acupuncture Project to release records will expire after my records have been released to the above specified person or organization.

Revoking authorization

I understand that I may revoke this authorization at any time except to the extent that action has already been taken based on this authorization.

Limitation on record protection

I understand that if this information is disclosed to someone who is not required to comply with federal privacy regulations, then the information may be re-disclosed and would no longer be protected.

Authorization is voluntary

I understand that authorizating the disclosure of these records is voluntary. I can refuse to authorize the disclosure.

Patient Signature

I have read and understand the above information. By checking this box, I authorize Brooklyn Acupuncture Project to release my records according to the terms described above.

Submit

Clear form

Never submit passwords through Google Forms.

Forms

This form was created inside of Brooklyn Acupuncture Project.