RECORD RELEASE FORM FAS
Medical Records
How to Obtain Your Clinic Medical Record
If you would like to personally pick up your records
- Specify on your request that you would like to pick up your records
- Be sure to provide a contact phone number where we can reach you
- If records are needed by a specific date, please specify that on your request
- A valid driver’s license or other form of picture identification is required to pick up copies of your records.
There may be a charge for your records
- There is no charge for records if you need them for continuation of care
- If you are requesting records for personal use there is .50 cents per page charge for the copies.
How long should the process take?
- In most cases record copies are available in less than a week.
- Some requests take longer to process. If you have questions you may call the number above to verify the status of your request
AUTHORIZATION FOR DISCLOSURE of PATIENT INFORMATION
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I hereby authorize FOOT & ANKLE SPECIALISTS
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FROM:
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I hereby authorize FOOT & ANKLE SPECIALISTS
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The Following Information Requested: (Check all that apply)
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Please note, items will not be faxed if file is more than 25 pages
Special Limitation to EXCLUDE the following protected information from this authorization:
This authorization may be revoked at any time by notifying FOOT & ANKLE SPECIALISTS in writing. This Authorization will remain in effect for 120days.
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By submitting your signature, the parties agree that this agreement may be electronically signed. The parties agree that the electronic signatures appearing on this agreement are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.
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