Request of Records (use this form if lowell community health wants records from prior facility )

Lowell Community Health Center Health Information Department 161 Jackson Street, 2nd Floor Lowell, MA 01852 978.322.8680 Phone 978.446.9830 Fax I ealth_information@lchealth.org (email)
HEALTH CENTER
Consent to Request Health Records
Patient Name
Date of Birth

MonthDayYear
Date
Address
Home Number
Cell Number
1 I hereby authorize and consent to the release of the health records obtained in the course of my treatment at
and fumish same to: Lowell Communlty Health Center Health Information Department, 2nd floor 161 Jackson Street Lowell, MA 01852 Continuity of Care 3. The specific information to be released is (please check off):

Last HX/PE Immunizations/PPD Lab results from past year Health maintenance screens PAP, ABD US Male >65 Mammogram Colonoscopy Dexa

Office / Clinic note from the past year Hospitalizations/Surgery Imaging Other (specify):
Specific Information to be released

Last HX/PEImmunization/PPDLab results from PastHealth MaintenanceOther
4. If my Initials appear here, | specifically authorize release of drug, alcohol abuse, sexually transmitted disease and/or counseling/psychiatric records. I understand that my drug treatment records are protected by federat regulation "Confidentiality of Alcohol and Drug Abuse Patlent Records, 42 CFR Part 2, Subpart C" and cannot be disclosed without my written consent otherwise provided in the regulations.
If my Initials appear here
5. If my Initials appear here,I specifically authorize release of my records that contain information about my HIV diagnosis, tests or treatment of HIV and AIDS, and which may contain reference to my identity as HIV positive or as an AIDS patoent.
If my Initials appear here
6. I have carefully read and understand the above statements and do herein expressly and voluntarily consent to disclose of the above informatlon about or health records of my condition to authorize personnel of Lowell Community Health Center.

7. I understand this consent is subject to revocation at any time, except to the extent that disclosure made in good faith has already occurred. Revocation must be made in writing. This authorization will explore in one year from the date shown below.

8. Information release may be subject to re-disclosure by recipient
DATE

MonthDayYear
Date
SIGNATURE

Clear
Authority of relationship of representative
Lowell Community Health Center Health Information Department 161 Jackson Street, 2nd Floor Lowell, MA 01852 978.322.8680 Phone I 978.446.9830 Fax I Health_information@lchealth.org (email)
HEALTH CENTER
Health Record Number
Witness
Interpreter
Should be Empty:

HEALTH CENTER

HEALTH CENTER