SMDC Release of Information Form

In order for the SMDC Health System to process your request for the release of your medical records, you must complete a form called the Authorization for Use and Disclosure of Protected Health Information. We cannot process an incomplete form so it is important that you complete each section.  Click here for instructions.

After you complete each section, click on "View Printable Form." This will bring you to a new page, which has all the information that you entered on a printable form. Print two copies of this form: one to mail to the appropriate facility and one to keep for your records.
Patient Name
First name:
Last name:
Middle initial:
Date of Birth
  ex:  MM/DD/YYYY
Medical Record Number (optional, if you know it)
I Hereby Authorize
To Release Information to
Individual's/provider's name:
Facility/organization:
Address:
City, state and zip:
Date and Time of Upcoming Appointment (if applicable)
  ex:  MM/DD/YYYY 00:00 AM/PM
Purpose of Disclosure
Continuing Care
Payment of Claim
School
Worker's Compensation
Legal
For Personal Use
 Other (specify):
Information to be Released (check all that apply)
Between dates/years of:  to
Discharge Summary
H&P Exam/Initial Evaluation
Consult
CD Counselor/Therapist Reports
Progress Notes/Provider Notes
Orders
X-Ray Reports
X-Ray Films/MRI
Diagnostic Test Reports 		Procedure Reports
Lab Reports/Pathology
Correspondence
Psychiatric Testing
Transfer/Outside Information
Completed Form
Exchange of Verbal Communication
HIV-related Information (AIDS related testing)
Other (specify content and dates)
All information regarding Alcohol and /or Drug Abuse or Behavioral Health will be released unless you have the boxes checked below.
Do not release Alcohol and/or Drug Abuse information
Do not release Behavioral Health information