Medical Records of (Patient Information)

Covering the date(s) of service from:

to:

Purpose:

At the Request of the Patient Continuing Care Attorney Other (specify):

*Rapid City Medical Center does not forward healthcare records of other healthcare entities, if any, as we cannot verify completeness*

AUTHORIZATION: I certify that this request has been made voluntarily and that the information given above is accurate to the best of my knowledge. I understand that I may revoke this authorization at any time by submitting my request in writing. I understand that I do not have to sign this authorization. I understand that my treatment or payment for services will not be denied if I do not sign this form. Without my express revocation, this authorization will expire in 180 days from date of signature unless I direct a different expiration date here .

COPY OF AUTHORIZATION: A copy or fax of this authorization may be utilized with the same effectiveness as the original unless otherwise noted in writing. A copy of this signed authorization will be provided to the patient.

RE-DISCLOSURE: I understand the information disclosed by this authorization may be subject to re-disclosure by the recipient and no longer be protected by federal privacy laws or regulations.

If you would like these records sent electronically, please check the following box and specify how you would like them sent.

For example, if you would like the records sent by email, please specify the email address we should send to:

SIGNATURE:

Please use finger or stylus to sign. If using a mouse, click and hold to sign.

Reset Signature

Signature Date:

If other than the patient, indicate the relationship to:

Parent Guardian / Legal Representative Other: