PATIENT AUTHORIZATION FOR THE DISCLOSURE OF
PROTECTED HEALTH INFORMATION
FROM ANOTHER FACILITY
______________________________________________________ ____________________________
Name of Patient (please print) Date of Birth
______________________________________________________ ____________________________
Street Address City State Zip Phone Number
______________________________________________________
Maiden name or other name used for on records
I hereby authorize: (please print) To release to:
______________________________________________________ Mount Laurel Family Physicians
______________________________________________________ 204 Ark Road, Suite 103
______________________________________________________ Mount Laurel, NJ 08054
the following information from my records:
____ Complete Medical Record
____ Medical Record (s) from Dr(s) ________________________________________________________________
____ Other (please specify) ______________________________________________________________________
Covering the period from __________________ to __________________
I understand that this may include information relating to
- Acquired Immunodeficiency Syndrome (AIDS) or Human Immunodeficiency Syndrome (HIV) infection
- Psychiatric care
- Treatment for alcohol and/or drug abuse
This information is to be disclosed for the purpose(s) of ____________________________________________________
Specify the date, extent or condition upon which this authorization expires _____________________________________
I understand that I have the right to revoke this authorization at any time. I understand that in order to revoke this
authorization, I must do so in writing and present my written revocation to Mt Laurel Family Physicians at the above
address. I understand such revocation will not apply to information already released in response to this authorization. I
understand that the revocation will not apply to my insurance company when the law provides my insurer with the right to
contest a claim under any policy. Unless otherwise revoked, this authorization will expire in 6 months from the date
below. I understand that any disclosure of information carries with it the potential for an unauthorized redisclosure and
the information may not be protected by federal confidentiality rules.
This release form was executed by Mount Laurel Family Physicians on the behalf of our patient in an effort to obtain
medical records from the above stated facility.
_________________________________________________________ ___________________________________
Signature of Patient (18 years or older) or Legal Representative Date
_________________________________________________________ ___________________________________
Printed Name of Patient’s Representative Relationship to Patient