Sometimes, you might want to transfer your medical records or share your protected health information (PHI) with a third-party, like a pharmacy or an outside provider. To get started, you may need to sign a release form. This form documents your consent and lets you specify where and to whom you want your records to be sent. It's a simple and quick process that ensures your medical records are sent exactly where you want them to go!
When do I need to complete a Release Form?
There are several situations when you may need to complete a release form:
Transferring your care from Circle Medical to an outside provider
Sending your medical records to a pharmacy that is not documented in your chart
Releasing your medical records in response to a request that hasn't been signed by you
How do I complete a Release Form?
If you need to complete a release form, you will receive an email with instructions on how to sign the form electronically using Dropbox Sign. The form may already contain your full name, date of birth, the name of the provider or pharmacy, and the specified records (if applicable).
The release form will have eight fields that require your attention:
Check Boxes (3)
“I authorize Circle Medical to disclose/release a copy of my protected health information (PHI) indicated to the location provided below:”
Check this box to authorize consent to release your medical records
“All PHI including provider notes, medication lists, discharge summaries, emergency department records, procedure/operative reports, immunization records, & radiology records.”
Check this box if you want all of your medical records to be sent
“Specific records pertaining to”
Check this box if you would like specific records to be sent
Initial Boxes (3)
If you've checked off “All PHI…” or “Specific records pertaining to” and the below is included in your medical records, please enter your initials.
“Mental health or developmental disability treatments records (excluding psychotherapy notes)”
Enter your initials if you would like these to be released
“Substance abuse disorder treatment, facility, or program notes”
Enter your initials if you would like these to be released
“HIV infection status”
Enter your initials if you would like these to be released
Text Boxes (2)
Patient Name *Required
Enter your full name
Patient Signature *Required
Sign the form
Once you have completed the required fields, click “Next > Continue > I agree.” You will receive a confirmation that the form has been submitted.
What happens now?
After completing the release form, notify the Medical Records Specialist that you have finished the form. They will fax the form along with the specified records to the appropriate recipient. Signing the release form ensures that we have your documented consent and that your medical records are sent where you want them to be sent and to whom you want them to be sent.