TVC & FHP Hospital Based Clinics Patient Records Request
Authorization to use or disclose protected health information

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* Patient Name

First

Last

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* Patient Date of Birth

Please enter patient's date of birth

Date

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* Email

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* Address

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* Phone Number

Medical Records
Define your record request below.
Note Radiology images need to be requested through the Fairbanks Imaging & Breast Center by clicking here

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* Dates of Treatment

And

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* Describe Records Needed

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* Purpose

Personal

Continuation of Care

Recipient Contact Information

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* Recipient Name/Facility

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* Record Format & Delivery

Email (PDF) copy

Fax

Mailed Paper Copy

Pick up

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* Recipient email address or fax number

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* Additional Recipient Contact Information

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* REQUIRED Photo ID

Attach a copy (image) of your Photo ID Examples: driver's license, passport, state-issued ID card

PDF, DOC, DOCX, PNG, JPG, JPEG file types only.

Choose File

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* RELEASE AUTHORIZATION
I understand that information in my health record may include information relating to Sexually Transmitted Disease, Acquired Immunodeﬁciency Syndrome (AIDS), Human Immunodeﬁciency Virus (HIV) and other communicable diseases, Behavioral Health Care/ Psychiatric Care, treatment of alcohol and/or drug abuse and genetic testing; my signature authorizes release of any such information.

I may refuse to sign this authorization form. I understand that Foundation Health Partners will not condition or deny treatment on my signing this authorization. I understand that I may revoke this authorization at any time, except to the extent that action based on this authorization has already been taken. Foundation Health Partners’ Notice of Privacy Practices explains the process for revocation, which includes a request in writing.

Unless I revoke this authorization earlier, it will expire 6 months from the date signed.

I understand that, if this information is disclosed to a third party, the information may no longer be protected by state, federal regulations and may be re-disclosed by the person or organization that receives the information.

I release Foundation Health Partners, its employees and agents, medical staff members, and business associates from any legal responsibility or liability for the disclosure of the above information to the extent indicated and authorized herein.

Typing my full name and date in the boxes below serves as my signature and authorization to release my information

Signature of patient or legal representative:

Full Name of Requester

Today's date

TVC & FHP Hospital Based Clinics Patient Records RequestAuthorization to use or disclose protected health information

Question Title

* Patient Name

Question Title

* Patient Date of Birth

Question Title

* Email

Question Title

* Address

Question Title

* Phone Number

Question Title

* Dates of Treatment

Question Title

* Describe Records Needed

Question Title

* Purpose

Question Title

* Recipient Name/Facility

Question Title

* Record Format & Delivery

Question Title

* Recipient email address or fax number

Question Title

* Additional Recipient Contact Information

Question Title

* **REQUIRED** Photo ID

Question Title

Question Title

* Relationship to Patient

TVC & FHP Hospital Based Clinics Patient Records Request
Authorization to use or disclose protected health information

* REQUIRED Photo ID