Medical Records Request

Please fill out the following form to request your medical records.  A Nashville Medical Group representative will contact you once the request is processed. To prevent a delay in your request, please fill out all form fields.


Full Name:
Social Security Number:
Date of Birth:
Phone Number:


Use my health information as described below; and/or
Disclose my health information to the following individual or organization:

Full Name / Organization:
Address:

City:
State:
Zip:


The purpose(s) for the use or disclosure is as follows:


Health information covering treatment time period:
from:
to:


The type and amount of information to be used or disclosed is as follows:
Copy of Complete Record
Abstract (Includes H&P, Progress notes, Procedure reports, Consult, DS, Diagnostic Testing, and all dictated reports.)
History and Physical (H&P)
Consultation
Discharge Summary (DS)
Operative / Procedure Report (OP)
Pathology Report
Labortory Report
X-Ray Report
Other, please give details below


I understand that my health information may include information relating to sexually transmitted disease,acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV). It may alsoinclude information about behavioral or mental health services, and treatment for drug and alcohol abuse.

I understand that I have a right to revoke this authorization at any time. I understand that, if I revoke thisauthorization, I must do so in writing and present my written revocation to the Director of Operations. Iunderstand that my revocation will not apply to the extent that Nashville Medical Group has taken inreliance on this authorization. I understand that my revocation will not apply if this authorization wasobtained as a condition of obtaining insurance coverage and the law provides my insurer with the right tocontest a claim under my policy or the policy itself. Unless otherwise revoked, this authorization will expireon the following date, event, or condition: . If I fail to specify anexpiration date, event, or condition, this authorization will expire in six months.


I understand that authorizing the disclosure of this health information is voluntary. I can refuse to sign thisauthorization. Nashville Medical Group may not condition treatment, payment, enrollment in its healthplan, or eligibility for benefits on my signing this authorization. I understand that if I authorize NashvilleMedical Group to disclose my health information, the health information may be subject to redisclosure bythe recipient and may no longer be protected by certain federal privacy regulations. If I have questionsabout disclosure of my health information, I can contact the Director of Operations at 615-284-1400.