Ellsworth Uveitis and Retina Care

Request for Medical Records

Ellsworth Uveitis and Retina Care

35 Eastward Lane
Ellsworth, Maine 04605
Telephone: 207.669.4390
Fax: 207.669.4363

Authorization to Release Health Care Information to Ellsworth Uveitis and Retina



Name:

Address:

Date of Birth:




I, , hereby authorize 
, its employees, and its agents to disclose and discuss records containing the following information to Ellsworth Uveitis and Retina Care. 

Please Forward:
  All of my treatment record information, including history, dates, course and summary of treatment received here. This information may be written or in electronic form.
  Hospital Records (In & Outpatient)
  Test Results
  Treatment records on file from other health care practitioners.
  Statements I have added to my treatment records, with responses, if any.
  Only
  All of the Above
This information may be used for:
  Ongoing treatment / aftercare
To coordinate treatment efforts with other physicians, family, and others
Transfer of care
Other
 
I Do I Do Not authorize the release of any information relating to the diagnosis or treatment of CHEMICAL/ALCOHOL DEPENDENCY under this authorization. If I authorize the release of this information, I understand that such information cannot be re-disclosed by a recipient without my specific consent.

  I Do I Do Not authorize the release of any information relating to the diagnosis or treatment of MENTAL HEALTH under this authorization. If I authorize the release of this information,  I Do I Do Not want to review this information before it is released. I understand that such information cannot be re-disclosed by a recipient without my specific consent.

  I Do I Do Not authorize the release of any information which refers to treatment or diagnosis of HIV, AIDS, or Sexually Transmitted Disease.


My consent to release these records is effective until (not to exceed 24 months)and I authorize future disclosures regarding these records to the same individuals or entities during this time period.


I understand that:

I can revoke all or part of this authorization at any time by notifying(individual or institution from whom you are requesting information) in writing, subject to the rights of anyone who received or disclosed information prior to receiving my revocation.

I can refuse to disclose all or some of the information in my treatment records. A refusal or revocation to release some of the information may result in improper diagnosis or treatment, denial of insurance coverage or a claim for health benefits, or other adverse consequences.



(Please sign and write the date that you signed after printing out this form)



Signed:______________________________________________
(patient or legally appointed representative)


Date:________________________________________________



Patient Name:


Patient's Social Security Number:


Patient's Address:

                             

                             


Release Valid Until:


(Once submitted, this form will be sent to an EURC representative who will make sure it is correctly filled out and then email it back you. Once you have received that email, please print off the form and bring it to your medical record issuer. If you would prefer to simply fill out the form by hand, then write down your email address below and send it to us. We will then email you a blank form to print out.)


Email Address:




                            Date Accessed: 


















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