Outgoing Medical Records Release

I am an:*

Intended Parent/Fertility Patient

Egg Donor

Gestational Carrier (Surrogate)

Patient Name*

First Middle Last

Date of Birth*

Social Security#*

Contact Phone*

Email Address*

I authorize and request The Fertility Center of Las Vegas and Ovation Fertility to use and disclose (verbal or written) all my protected health information (including financial & medical services, diagnosis, and treatment received) below to the authorized individual/company listed below (select all that apply):

Person/Company Receiving your PHI*

An Individual/Person

A Business/Agency

A Medical Office

Name of Individual/Person (you can add multiple names)*

Individual/Person Fax number or Email Address for where to send records*

Business / Agency Name (you can add multiple business names)*

Business Fax or Email Address for where to send records*

Medical Office Name*

Medical Office Fax or Email Address for where to send records*

Protected Health Information (PHI) includes all medical records, meaning every page in my record, including but not limited to: history & physical, office/clinical/consultation notes, inpatient/outpatient treatment, all clinical charts, reports, lab results, progress notes, nurses notes, medical records received from another provider, billing and insurance records pharmacy/prescription records including NDC numbers and drug information handouts/ monographs.

I authorize the disclosure of*

All PHI related to me which may include confidential information related to communicable diseases, sexually transmitted diseases (including HIV or AIDS), alcohol or drug abuse, genetic information, and blood/breath/urine screens.

ALL PHI related to me except for:

ONLY the following PHI related to me:

PHI related to me that I DO NOT AUTHORIZE to be disclosed:*

I authorize ONLY the following PHI to be disclosed:*

I understand:

Any facsimile, copy or photo of the authorization shall authorize The Fertility Center/Ovation Fertility to release the records requested herein.
This authorization will expire two years after the date of birth of any resulting infant, or two years after terminating treatment with our clinic, or two years after form is completed, whichever happens last.
This authorization may be revoked in writing at any time except to the extent information has been released in reliance upon this authorization.
Treatment or payment for treatment cannot be conditioned on my providing this authorization unless the provision of health care is solely for the purpose of creating protected health information for disclosure to third party.
The information released may contain protected health information from another provider.
The Fertility Center/Ovation Fertility cannot control if the information released in response to this authorization is re-disclosed to other parties.
I have a right to receive a copy of the information disclosed per this authorization*.

*Medical Records Copying Policy: There will be a .60 cents per-page fee for photocopies of medical records. The fee will be waived for medical records released to a physician’s office, agency and/or response to a subpoena. Medical records will be ready within 10 business days after the date of receipt of the request. Only the patient requesting the records may receive them in person and will be verified by a photo ID.

Please enter in the name of any Personal Representatives that you authorize to pick up a copy of your printed PHI medical records at The Fertility Center of Las Vegas

Printed Name of Personal Representative

First Last

Copy of Patient Photo ID*

Max. file size: 50 MB.

Our office will contact you at the contact phone/email listed above to verify this form. Please contact us at (702) 254-1777 if you do not hear from us within 3 business days of completing this form.

Date*

Signature of Patient*