Medical Release Form

At A Woman’s View, we value the confidentiality and privacy of your medical information. To facilitate the process of sharing your medical records when needed, we provide an easy-to-use Medical Release Form. Here are some key features and instructions for using our Authorization for the Release of Medical Information form:

Purpose of the Form The Medical Release Form allows you to authorize the release of your medical records to another healthcare provider, institution, or specified individual. This ensures that your health information is shared safely and efficiently, whether for continued care, specialist consultations, or personal use.

Features of the Medical Release Form

• Patient Information: Clearly fill out your personal details, including your name, date of birth, and social security number, to ensure accurate identification.
• Receiving Organization Details: Specify the name and contact information of the organization or individual to whom the records will be released.
• Purpose of Disclosure: Indicate the reason for the release of your medical records.
• Time Period: Define the time frame for the records being requested.
• Authorization Statement: Initial and sign the required statements to confirm your consent and understanding of the authorization process.

How to Use the Medical Release Form

1. Fill Out the Form: Complete all required fields with accurate information.
2. Specify Records: Clearly describe the medical records you wish to release.
3. Sign and Date: Ensure that both the patient (or their representative) and the provider sign and date the form.
4. Submit the Form: Submit the completed form to A Woman’s View for processing.

Additional Information

• Revocation: You may revoke this authorization at any time by providing written notice to A Woman’s View. This will not affect any actions taken prior to the receipt of the revocation.
• Inspection and Copies: Patients and their representatives have the right to inspect and copy the health information to be disclosed.
• Voluntary Authorization: Providing this authorization is voluntary, and your treatment or payment will not be conditioned on signing this form, except in specific circumstances permitted by law.

Contact Us If you have any questions or need assistance with the Medical Release Form, please do not hesitate to contact our office.

• Address: 915 Tate Blvd. SE, Suite 170, Hickory, NC 28602
• Phone: (828) 345-0800
• Fax: (828) 345-0350

Download the Authorization for the Release of Medical Information Form Here

Thank you for choosing A Woman’s View. We are committed to providing you with comprehensive and confidential healthcare services.