“Written Authorization to Release Copies of Healthcare Information”

Instructions for Completing the Form

·  Patient Name, Date of Birth, and Contact Telephone Number:

Enter name of the patient whose records are being released, along with the patient’s date of birth and telephone number.

·  Where Records are Now (releasing from):

Enter name, address, telephone number, and fax number of the facility or office practice where the medical records are currently located.

·  Where Records are Going (release to):

Enter the name, address, telephone number, and fax number (if applicable) of the facility, office practice, organization, or person to whom the patient’s medical records should be sent.

(Please note-We do not fax to a patient’s home or place of employment.)

·  Purpose of the Release:

Enter the purpose/reason for which you are requesting records to be released. For example, please tell us if you need the medical records for a doctor’s appointment, insurance company, your lawyer, if you need them for yourself, or for any other reason.

·  Date(s) of Service:

Enter the date range of the medical records to be released.

·  Information to be Released:

Please check mark the specific types of information you want to be released. It is helpful to provide specific dates of service. You may be contacted if you are requesting all records to provide us with further clarification.

·  I DO authorize the release of information regarding DRUG and/or ALCOHOL ABUSE. By Federal law, this information may not be re-disclosed by the recipient without a special consent.

This statement authorizes the release of information in the medical record that references any drug and/or alcohol abuse. If this type of information is to be released – or if this statement does not apply, nothing needs to be completed. If you DO NOT WANT this type of information released, it is important for you to initial the “I DO NOT” section to the far right side.

·  I DO authorize release of information regarding MENTAL HEALTH treatment.

This statement authorizes the release of information in the medical record that references mental health treatment. If this type of information is to be released – or if this statement does not apply, nothing needs to be completed. If you DO NOT WANT this type of information released, it is important for you to initial the “I DO NOT” section to the far right side.

·  I DO authorize disclosure of information regarding HIV Infection, ARC (AIDS-Related Complex) or AIDS.

This statement authorizes the release of information in the medical record that references an HIV infection, ARC (AIDS related complex) or AIDS. If this type of information is to be released – or if this statement does not apply, nothing needs to be completed. If you DO NOT WANT this type of information released, it is important for you to initial the “I DO NOT” section to the far right side.

·  I DO waive the right to review records before they are released. I understand that such review must be supervised.

This statement allows the release of the medical records without prior review by the individual signing the form. If the records are to be released without prior review, nothing needs to be completed on the form. If the individual would like to review the medical records prior to release, the “I DO NOT” line must be initialed. Also, an appointment must be arranged in advance so that the records are reviewed under the supervision of a clinical professional.

·  Informational Statements:

Informational statements have been provided for your review. Please take a moment to read these statements. This authorization to release medical records expires 12 months from the signature date. If you would like it to expire sooner, please enter a date.

·  Patient Signature:

A signature and date is required for all patients 18 years and older and legally emancipated minors with supporting legal documents. In other cases when minors have sought treatment for specifically defined treatment and when treated as adults, the minor may then sign and date the form to release the medical records associated with the specific treatment.

·  Authorized Representative / Relationship:

If a patient has a legal guardian or POA (power of attorney), the individual acting on behalf of the patient must sign and date the form. If there is an Executor or Court Appointed Representative of a patient’s estate, the appointed individual must sign and date the form.

**A copy of the legal documents must be provided with the completed request form.**

·  Witness:

The signature and date of witness is preferred. The witness is attesting only to have actually observed the patient sign the form.

Please return the completed request to medical records by mail, fax, or email, and we will forward your records as requested.

Hospital Record Requests:

Mailing Address:

St. Joseph Hospital

Health Information Department-ROI

360 Broadway

Bangor, ME 04401

Fax Number: 207-907-1103

E-mail: or

****Please call 207-907-1377 or 207-907-1378 with any questions****

Physician Office Record Requests:

Mailing Address:

St. Joseph Physician Practices

Medical Records-ROI

P.O. Box 934

Bangor, ME 04402

Fax Number: 207-907-3403

E-mail: or

****Please call 207-907-3341 or 207-907-3209 with any questions****