Medical Records Release Form

Medical Records Release Form

"*" indicates required fields

Name*
MM slash DD slash YYYY
Address*

RECORDS TO BE SENT FROM:

Address

RECORDS TO BE SENT TO:

Address
Allure Health
7000 S. Lyncrest Place
Sioux Falls, SD 57108
p. 605-271-5441
f. 605-271-5277

WHAT INFORMATION IS NEEDED FOR RECORDS REQUEST.

PLEASE CHECK THE APPROPRIATE BOXES*
Other:
Information will be disclosed because of:

Sign & Date

My Signature, electronic or in ink, is approval of my authorization. I authorize the above named Provider(s), employed by the above-named Medical Practice(s), and Medical Practice(s), 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 detailed information related to STIs, AIDS, HIV, or mental health services and treatment programs. This authorization is valid until rescinded, and I will contact Storm Clinic Prof. LLC dba Allure Health to sign and rescind the above authorization if I so wish.
MM slash DD slash YYYY