Medical Records Release Form

Name*

First Last

Date of Birth*

Email*

Address*

Street Address Address Line 2 City State ZIP Code

Phone*

Cell Phone

RECORDS TO BE SENT FROM:

Name

First Last

Facility

Address

Street Address Address Line 2 City State ZIP Code

Phone

Fax Number

RECORDS TO BE SENT TO:

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

Specify the Allure Doctor or Department your records be sent to:

WHAT INFORMATION IS NEEDED FOR RECORDS REQUEST.

PLEASE CHECK THE APPROPRIATE BOXES*

Other:

Additional Notes from Requesting Facility:

Information will be disclosed because of:

Transferring care

Referral to Specialist

Legal Issues

Patient Request

Sign & Date

My 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*

Today's Date*