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Medical Records Release Form

  • Medical Records
  • Authorization for Exchange of Confidential Information

  • I am, hereby authorize Optimotion Orthopaedics to (check one) release / obtain all medical, psychiatric, alcohol and/or drug abuse, HIV testing, ARC and/or AIDS diagnosis and information to/ from:

  • Continued Medical Care Second Opinion Insurance Attorney Personal
  • For Release Only: Are you transferring your total care to/from Optimotion Orthopaedics to/from the provider mentioned above: Yes/No

    I understand this consent is revocable upon written notice to Optimotion Orthopaedics, Steve Nguyen M.D., or Nam Dinh, M.D., except to the extent that the action by Optimotion Orthopaedics has already been taken on by this authorization. This authorization shall remain in force for a reasonable time to accomplish the purpose for which it is given, or will expire (in six (6) months).

    I hereby release Optimotion Orthopaedics, and its employees, agents, officers and affiliates, from any and all legal liability, responsibility, claim and damage that may arise from the release of information as requested.

    Alcohol and drug abuse information, if present has been disclosed from records whose confidentiality is protected by Federal Law. Federal regulation (42CFR, part 2) prohibits making any further disclosure of the information without the specific written authorization of the undersigned, or as otherwise permitted by such regulations.

    Notice to Requesting Party: There will be cost associated with this request. Your signature on this form indicates your knowledge of the fee. The medical records will be provided after the fee is paid.

  • Complete Medical Record X-Ray Disc ($10 fee) Surgical Report Office Notes Radiology Reports Other (Specify)

    Records Date Range (If Applicable) through

  • Fax Mail Secure Email Pick Up
  • * We care about your privacy. By checking this box you confirm that you have read and understood our privacy policy and consent to provide your personal information to us