Authorization to Release PHI Medical Records Release Authorization Your first name(Required)Middle nameLast name(Required)Patient D.O.B.(Required)Today's date MM slash DD slash YYYY Name of Person Receiving Medical Records(Required)Address Receiving Medical Records(Required)FAX NumberEmail address(Required) Enter Email Confirm Email Records to sendRecords to send 1 Office Notes Laboratory Tests Insurance Information Billing Statements Records to send 2 MRI EEG CAT Scan Forms Records to send 3 EMG MRA Letter Other Other Records Needed…Request SpecificationsReason for RequestRecords Start Date MM slash DD slash YYYY Records End Date MM slash DD slash YYYY Expiration Date MM slash DD slash YYYY I understand that the information in my health record may include information relating to sexually transmitted disease, acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV). It may also include information about behavioral or mental health services, and treatment for alcohol and drug abuse. By signing this authorization, I authorize Neurology Center of Fairfax, Ltd. to use and/or disclose certain protected health information (PHI) about me. When my information is used or disclosed pursuant to this authorization it may be subject to redisclosure by the recipient and may no longer be protected by federal HIPAA privacy rules. I have the right to revoke this authorization in writing. My written revocation must be submitted to the Privacy Officer at the Neurology Center of Fairfax: 3020 Hamaker Ct #400, Fairfax, VA 22031. This authorization will automatically expire 1 year from date signed unless otherwise indicated.Patient Name(Required)Consent(Required) By checking this box, I – the authorized person named here – am signing this document.Date(Required) MM slash DD slash YYYY Rev 7.13.2022PhoneThis field is for validation purposes and should be left unchanged.