Medical Record Request | Re:Vision Rubinfeld

Authorization for the release of patient medical records from Dr. Rubinfeld’s offices to another healthcare provider.

This Authorization form is designed to meet the requirements of federal privacy regulations issued by the Department of Health and Human Services at 42 CFR § 164.508 and the Annotated Code of Maryland, Title 10 Health General Article §§ 4-301-4-307.

Medical Record Request

Confirmation

I hereby authorize Dr. Roy Rubinfeld to release my protected health information.

Patient First Name

Patient Last Name

Patient Date of Birth

Patient Email

Patient Address

I request that the information be released to the following doctor’s office:

Doctor Address

Doctor Phone

Doctor Email

Doctor Fax

This authorization will expire one year from the date it is signed unless a shorter time is indicated here:

This authorization is voluntary. This request may take up to 48-72 business hours. My treatment, payment for it, and/or eligibility for enrollment or benefits cannot be conditioned on my signing this authorization form.

I may receive a copy of this form.
I may inspect my protected health information without signing this form.
This authorization to disclose information may be revoked by me at any time, expect to the extent that the action has been taken prior to receipt of revocation. To revoke the authorization, I understand that I must notify Re:Vision in writing.
I understand that once information covered by this authorization has been disclosed re-disclosure of information by that recipient is possible and the information may no longer be protected by the federal regulations referenced above but may be protected by Maryland law.

I agree to these terms and conditions.

Patient or Personal Representative Signature

Clear

If signature is other than patient, explain your authority to act for the patient:

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Rockville Office

Fairfax Office

Hours

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