Patient form · About 4 minutes

Authorization to release or request medical records

Use this to authorize us to request your records from another office, or to release your records elsewhere.

About you

Full name*

Date of birth*

Telephone

Please give at least a telephone number or an email address so the office can reach you.

Direction of the request

What would you like us to do?*

Request records from another officeRelease my records to another office or person

Name of the other practice, clinician, or person*

Their address*

Their phone or fax

What is covered

Records requested — for example visit notes, laboratory results, imaging, immunizations

Date range of records

Do you authorize the release of mental health, substance-use, or HIV-related records?*

Yes, include themNo, exclude them

Purpose of the request*

Authorization

Authorization*

I authorize the disclosure described above. I understand this authorization is voluntary, that I may revoke it in writing at any time except where action has already been taken in reliance on it, that it expires one year from the date signed unless I specify otherwise, and that information disclosed to a recipient who is not a health plan or healthcare provider may no longer be protected by federal privacy law.

I have read and agree to the statement above.

Type your full legal name as an electronic signature*

Date*

Submitting sends your answers directly to K. Johns Medical over an encrypted connection and creates a PDF for your clinician. It does not book an appointment and is not monitored in real time. For an urgent concern, call the office. In an emergency, call 911 or call or text 988.

Authorization to release or request medical records

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