Release of Medical Records

Allow 5–7 business days for processing · Fields marked * are required

Patient Information

First Name*

Last Name*

Date of Birth*

Phone*

Address

Direction of Records

I am authorizing*

Other Provider / Facility

Provider / Facility Name*

Address

Phone

Fax

Records Requested

Type of records (check all that apply)

Complete medical recordOffice visit notesLab resultsImaging / radiologyOperative / procedure reportsDischarge summaryMedication listMental health recordsImmunization recordsReferral letters

Date range — From

Date range — To

Specific records or additional details

Purpose of Release

Purpose*

Additional notes

Authorization & Expiration

I authorize the use or disclosure of my protected health information as described above. I understand that I may revoke this authorization at any time by submitting a written request to Roth Family Medicine & Mental Health, except to the extent that action has already been taken in reliance on this authorization. This authorization will expire one year from the date of signature unless a different date is specified below.

Expiration date (optional — defaults to 1 year)

I authorize the release of my medical records as described above. *

Patient / Guardian Signature (type full name)*

Date*

Relationship to patient (if signing on behalf of patient)

Processing time: Please allow 5–7 business days. For urgent requests, call us directly at (208) 904-4705.

Comprehensive, integrative care for your whole health, body and mind. Serving Pocatello and the Portneuf Valley.

Services

Family Medicine Mental Health TMS Therapy Ketamine Assisted Psychotherapy Functional Medicine Hormone Therapy

Practice

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Contact

444 Hospital Way, Suite 422

Pocatello, Idaho 83201

(208)-904-4705

Fax: (208) 203-6420

[email protected]

Mon–Thu: 9am–4pm