Authorization Of Records Release

**GOVERNMENT ISSUED PHOTO ID REQUIRED TO MATCH SIGNATURE BEFORE RECORDS CAN BE RELEASED (You will need to attach a copy of a government issued photo ID using the file uploader below)

Patient Name*

First Last

Address*

Street Address Address Line 2 City State ZIP Code

Date of Birth*

Phone*

I Authorize to release medical records from Fox Valley Pulmonary Medicine

Yes

Fox Valley Pulmonary Medicine SC
2500 Capitol Drive
Suite 2600
Appleton, WI 54911

RELEASE OF HEALTH RECORDS TO:

Name of Health Care Provider/Plan/Self/Other

Health Care Provider/Plan/Self/Other Address

Street Address Address Line 2 City State ZIP Code

INFORMATION TO BE RELEASED:*

Office Notes

Lab Reports

Sleep Study

Pulmonary Function Tests

X-Ray Reports

Hospital Notes

Other (Please specify below)

Please Specify Other Information To Be Released:

* If you'd like to pick up at Fox Valley Pulmonary Medicine, please specify which location:

In compliance with Wisconsin Statutes, which require special permission to release otherwise privileged information, please release records pertaining to:

Alcohol Abuse or Test Results

Drug Abuse or Test Results

Mental Health

Developmental Disabilities

HIV Test Results, AIDS issues

Sexually Transmitted Disease

Other (Please specify below)

Please Specify Records to be Released Pertaining to:

THIS DISCLOSURE IS BEING MADE FOR THE FOLLOWING PURPOSE(S):*

Medical Care

Relocation

Insurance

Legal

Other (Please specify below)

Please Specify Other Purpose(s):

Digital Signature & Date

I certify that this request has been made freely, voluntarily and without coercion and that the information given above is accurate and complete to the best of my knowledge. I may revoke this authorization in writing, at any time except to the extent that action has already been taken to comply with it. Any disclosure of information carries with it the potential for unauthorized redisclosure, and the information may not be protected by federal confidentiality rules.

Signature*

Signature Name*

First Last

If signed by other than patient, state relationship and authority to do so.

Parent

Guardian

POA for Healthcare

Spouse/Adult Family Member of Deceased Patient

Signature Date*

File Upload (5 MB Limit)

Accepted file types: jpg, jpeg, gif, png, pdf, Max. file size: 5 MB.

Files accepted: JPG, JPEG, GIF, PNG, PDF

To submit, what is 35+10=*

Name

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