Patient Records Relase Form

Pain Management Pharmacy can neither confirm nor deny the presence of patient records to entities with which we do not have a HIPAA-Compliant Business Associate relationship without a written copy of the patient’s notarized signature on a HIPAA-Compliant authorization to release records from a specific entity to a specific entity. ‘Blanket’ releases where the releasing entity is added after the document has been signed may be legally questionable. Workers’ Compensation requests must still provide a notarized signature to prove that the patient falls into this category.

To request patient records, please fax the completed form along with your request form to:

805-928-4710

Protected Health Information Release Authorization

[The patient or his court-appointed representative must provide a notarized signature in order for the pharmacy to consider releasing pharmacy records. Records received from the Department of Justice are not included in this release.  For signatures from other than the patient, please provide documentation that the signer is the current court-appointed patient representative.]

I, _________________________________, (Date Of Birth: __/__/__), authorize Pain Management Pharmacy, Inc. of Santa Maria, CA to release the records of my Protected Health Information that they have created and retained in the period from __/__/__ to __/__/__to ____________________________________ (requesting entity).

My physical address is: ______________________________________________

My contact telephone number/email is: _________________________________

 

Patient Signature                                                    Printed Name                                  Date

Notary Stamp: