Release of Records Form

The Release Form is used to request your health records from another provider’s office. Unless Anne Marie has received a referral from your primary, previous, or other provider, you will need to give them written authorization to send your records and indicate which records should be sent.

Here are the steps for completing the form and getting Anne Marie the records you intend:

- Download the Release Form here.

- Complete at the top of the form, NAME, ADDRESS, CITY, STATE of your previous provider.  You may write the form to an entire clinic (e.g. Oregon Medical Group) or a specific person (e.g. Dr. Daniel Salts). Include the name and address, at least the city, of the provider or clinic that you saw.

- In the next blank, write your name and date of birth in the spaces provided. If you are providing a maiden or other name, please include both your previous and current name.

- Now, indicate what records should be sent for what dates, and what restrictions apply. Our goal is to make the process as simple as possible for the provider to get Anne Marie the records that will be useful. Anne Marie recommends requesting “chart notes and lab results” for two years, by X-ing the second blank and filling in a date range from two years are to present. Please ask if you need guidance about the type of information to request.

- You should initial all 5 of the little blanks for disclosure of different types of protected information, if possible. Even if mental health, HIV, or  drug/alcohol treatment could not be among your records, the sending office may need to audit/scrub the records if you do not allow this disclosure. You have the right to have this information excluded, if you like, but often delays sending of records while the records are reviewed.

- Send the form to our office for tracking. Fax and postal addresses for our office are listed on the form.