Medical Record Request  Home 5 Medical Record Request (To be initiated by the Patient or the Patient’s Legal Representative)Patient Name* First Last Date of Birth* MM slash DD slash YYYY Social Security Number* Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code I hereby authorize the use and disclosure of individually identifiable health information relating to me, otherwise known as “protected health information” or “PHI” under a federal privacy law, as described below. I understand this authorization is voluntary. I consider a copy of this authorization to be valid as the original. I understand that if the organization authorized to receive the information is not a health plan or healthcare provider, the released information may no longer be protected by federal privacy regulations.Person(s)/organization(s) providing the information:* Name of person(s)/organization(s) receiving the information* Address or person(s)/organization(s) receiving the information* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Specific description of information to be released including date(s) and type(s) of service:*Purpose for which information is to be used:* Treatment Personal Insurance Follow-up Legal Other If Other, please specify belowSPECIFIC AUTHORIZATION FOR RELEASE OF INFORMATION PROTECTED BY STATE OR FEDERAL LAW I specifically authorize the release of data and information relating to (please initial appropriate box below and hereby release Neurology Consultants of Nebraska, P.C. from all legal liability that might arise from the release of sensitive information protected by Title 42 of the Code of Federal Regulations. *Substance Abuse (alcohol or drug abuse) *Behavioral Health (except psychotherapy notes which require a specific authorization) *HIV or other Sexually Transmitted Disease Related Informaitons (or AIDS related testing) I understand that I may revoke this authorization at any time, except to the extent that action has already been taken to comply with it, by writing to: Neurology Consultants of Nebraska, P.C. North Doctors Tower 4242 Farnam, Suite 500 Omaha, NE 68131 Without my written permission to revoke this authorization, it will automatically expire six months from the date of signature according to Nebraska Law. If you desire a specific date (not to exceed six (6) months), or event upon which this authorization will expire, please specify: I understand that I am entitled to a copy of this authorization form. I understand that I have the right to inspect or receive copies of my Protected Health Information (PHI) to be used and/or disclosed under this authorization, and that a fee for copies may be imposed by Neurology Consultants of Nebraska, P.C. or its designated Business Associate. Recipient Please Note: This information may have been disclosed to you from records whose confidentiality is protected by federal law. Federal regulation (42 C.F.R. Part 2) prohibits you from making any further disclosure without the specific written consent of the person to whom it pertains, or as otherwise permitted by such regulations.Today's Date* MM slash DD slash YYYY Signature of Patient or Patient’s Legal Representative*Printed Name of Patient’s Legal Representative* Relationship of Legal Representative to Patient*
