There are times when you may need to share your medical records or health information with a third party, like a pharmacy or another doctor. 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. This is important as it allows you to have control over who has access to your protected health information (PHI). It's also 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 profile
Releasing your medical records based on 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 be filled with your full name, date of birth, the name of the provider or pharmacy, and the specified records (if applicable).
The release form will have 8 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 to specify which records will be sent.
Initial Boxes (3)
If you've checked off “All PHI…” or “Specific records pertaining to...” and the content below is included in your medical records, follow the directions below.
“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 email informing you 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, as well as the records you have specified, to the appropriate recipient.
Remember, signing the release form gives us your documented consent to process the request and ensures your medical records are sent to the right place and person.