Medical Records Release FormMedical Records Release Form"*" indicates required fieldsName* First Last Date of Birth* MM slash DD slash YYYY Email* Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Cell PhoneRECORDS TO BE SENT FROM:Name First Last FacilityAddress Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code PhoneFax NumberRECORDS TO BE SENT TO:Allure Health 7000 S. Lyncrest Place Sioux Falls, SD 57108 p. 605-271-5441 f. 605-271-5277Specify the Allure Doctor or Department your records be sent to:WHAT INFORMATION IS NEEDED FOR RECORDS REQUEST.PLEASE CHECK THE APPROPRIATE BOXES* Dictation / Notes Labs Microbiology Imaging Tests Operative Reports Radiology Reports Medication Lists Progress Notes Consult Notes Cultures with Sensitivites and MicroOther: Add RemoveAdditional Notes from Requesting Facility:Information will be disclosed because of: Transferring care Referral to Specialist Legal Issues Patient RequestSign & DateMy Signature is approval of my authorization. I authorize the above named Physician and Medical Practice to release my protected health information to those identified on this release. I understand that if any person receives this information that is not covered by the federal privacy regulation, the release may no longer be protected. I understand that my health record may include sensitive and detaled related to STD’s, AIDS, HIV, or mental health services and treatment programs.Signature*Reset signature Signature locked. Reset to sign again Today's Date* MM slash DD slash YYYY
