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Med Rec Request SMHC

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If we need to call you regarding this request, do we have your permission to leave a detailed message at the number provided above?*
- Yes
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As specified below, I hereby authorize MaineOrtho - Norway, its authorized employees and agents to release, information from my health record to the individual listed below. The individual to whom records are to be released must be one of the following: Patient, Parent/Legal Guardian, or a Medical Provider (doctor, chiropractor, physical therapist, etc.).
As specified below, I hereby authorize MaineOrtho - Portland, its authorized employees and agents to release, information from my health record to the individual listed below. The individual to whom records are to be released must be one of the following: Patient, Parent/Legal Guardian, or a Medical Provider (doctor, chiropractor, physical therapist, etc.).
As specified below, I hereby authorize OA Centers for Orthopaedics - Brunswick, its authorized employees and agents to release, information from my health record to the individual listed below. The individual to whom records are to be released must be one of the following: Patient, Parent/Legal Guardian, or a Medical Provider (doctor, chiropractor, physical therapist, etc.).
As specified below, I hereby authorize OA Centers for Orthopaedics - Portland, its authorized employees and agents to release, information from my health record to the individual listed below. The individual to whom records are to be released must be one of the following: Patient, Parent/Legal Guardian, or a Medical Provider (doctor, chiropractor, physical therapist, etc.).
As specified below, I hereby authorize OA Centers for Orthopaedics - Saco, its authorized employees and agents to release, information from my health record to the individual listed below. The individual to whom records are to be released must be one of the following: Patient, Parent/Legal Guardian, or a Medical Provider (doctor, chiropractor, physical therapist, etc.).
As specified below, I hereby authorize OA Centers for Orthopaedics - Windham, its authorized employees and agents to release, information from my health record to the individual listed below. The individual to whom records are to be released must be one of the following: Patient, Parent/Legal Guardian, or a Medical Provider (doctor, chiropractor, physical therapist, etc.).
As specified below, I hereby authorize Central Maine Orthopaedics, its authorized employees and agents to release, information from my health record to the individual listed below. The individual to whom records are to be released must be one of the following: Patient, Parent/Legal Guardian, or a Medical Provider (doctor, chiropractor, physical therapist, etc.).
As specified below, I hereby authorize Falmouth Orthopaedic Center, its authorized employees and agents to release, information from my health record to the individual listed below. The individual to whom records are to be released must be one of the following: Patient, Parent/Legal Guardian, or a Medical Provider (doctor, chiropractor, physical therapist, etc.).
As specified below, I hereby authorize Orthopaedic Clinic at Bridgton, its authorized employees and agents to release, information from my health record to the individual listed below. The individual to whom records are to be released must be one of the following: Patient, Parent/Legal Guardian, or a Medical Provider (doctor, chiropractor, physical therapist, etc.).
As specified below, I hereby authorize Orthopaedic Clinic at Farmington, its authorized employees and agents to release, information from my health record to the individual listed below. The individual to whom records are to be released must be one of the following: Patient, Parent/Legal Guardian, or a Medical Provider (doctor, chiropractor, physical therapist, etc.).
As specified below, I hereby authorize Orthopaedic Clinic at Rumford Hospital, its authorized employees and agents to release, information from my health record to the individual listed below. The individual to whom records are to be released must be one of the following: Patient, Parent/Legal Guardian, or a Medical Provider (doctor, chiropractor, physical therapist, etc.).
Provider / Practice Site*
Address
Street Address City State ZIP Code
Phone
Fax
Date of Upcoming Appointment
MM slash DD slash YYYY

Please select the date of your upcoming appointment at Southern Maine Healthcare, if applicable.
How to Release*
INFORMATION TO BE RELEASED (Select only those which apply)*
- Office Visit Notes
- Operative Reports
- Radiology Reports
- Other Information (Specify below)
Other Specific Information*
Purpose of release
- Continuing Care
- Transfer of Care
- Personal Use/Review
- Other Reason (Specify below)
Other Specific Reason*
Required*
- I DO authorize disclosure of any information relating to alcohol and/or drug abuse treatment
- I do NOT
Required*
- I DO authorize disclosure of any information relating to treatment by a mental health professional or program
- I do NOT
(Maine law requires our practice to inform you that, if this information is misused, disclosing your HIV infection status may have consequences, such as negative treatment in your personal life or by insurance companies. It can be important for providing you needed services and healthcare.)

My specific permission is required to disclose information regarding HIV Test Results or Status I understand that authorizing the release of such information does not confirm the existence of such history or treatment. Check one of the two options below and initial at end to confirm your choice
Required*
- I DO authorize disclosure of information which refers to HIV test results, infection status, or treatment information
- I do NOT
- I am not required to sign this form and that I may refuse to disclose all or some of the above healthcare information in my treatment records, but that refusal may result in improper diagnosis or treatment, denial of coverage for a claim for health benefits, denial of other insurance, or other adverse consequences. I understand that all Spectrum Healthcare Partners and all affiliated orthopaedic practices will not condition treatment, payment, enrollment or eligibility for refusing to disclose information.
- PHI released pursuant to this authorization may include records generated by another healthcare provider or facility.
- I further understand that I may withdraw my authorization at any time except to the extent that action has been taken in reliance on this authorization. I understand that if I revoke this authorization, I must do so in writing and present my written revocation to the Privacy Officer at Spectrum Healthcare Partners. I understand that revocation may be the basis for denial of health benefits or other insurance coverage or benefits. For additional details and information I may read the Notice of Health Information Privacy Practices.
- PHI used or disclosed pursuant to this authorization may be re-disclosed by the recipient and no longer protected by confidentiality laws.
- A processing fee may be charged as permitted by law
- I am entitled to a copy of this authorization, upon request.
This authorization becomes effective immediately and shall expire one year from the date of signing
Name of person signing*

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