Download Consent for Medical Records to CCFW

CHATTANOOGA CENTER FOR WOMEN, PC & JACK ROWLAND, MD, PLLC
7490 Ziegler Rd. Chattanooga, TN 37421
Phone: 423.648.6020 / Fax: 423.648.6025
Gary A. Brunvoll, D.O.
Sabrina Collins, M.D.
Jack M. Rowland, M.D.
Sarah S. Smith, DNP, CNM
Katie Garrett, CNM
Amy Miller-Anderson, CNM Meg Brasel, CNM
Patient Name: __________________________________________________________________
First
Maiden
______/_____/_______
Date of Birth
Middle
_______-_____-________
Social Security #
Last
(_______) _______-__________
Current Phone #
I request and authorize the following Practice and/or facility to release my medical records to CCW or Dr. Rowland:
______________________________________________________________________________________
(Name of Dr., Hospital, Other)
Address
_______________________________________________________________________________________________________
City
State
Zip
Phone: (______)
_________-____________
Fax: (______)
________-___________
Definition: Sexually Transmitted Disease (STD) as defined by law, RCW 70.24 et seq., includes herpes, herpes
simplex, human papilloma virus, genital warts, condyloma, Chlamydia, non-specific urethritis, syphilis, VDRL,
chancroid. Lymphogranuloma venereum, HIV (Human Immunodeficiency Virus), AIDS (Acquired
Immunodeficiency Syndrome) and gonorrhea.
Yes
No
I authorize release of my STD results, HIV/AIDS testing, whether negative or positive, to the
person(s) listed above. I understand that the person (s) listed above will be notified that I must
give specific written permission before disclosure of the test results to anyone.
Yes
No
I authorize the release of any records regarding drug, alcohol, or mental health treatment to the
person(s) listed above.
____ Colonoscopy
____ CT Scan
____ Dexa Scan
____ Hida Scan
____ Holter Monitor
____ Labs
____ Mammogram Report
____ Operative Report
____ Pathology
____ Prenatal Records (labs, u/s’s, non-stress tests,
and hospital records)
____ Ultrasound Report (for non-OB pts only)
**_____ Other records i.e. financial, etc.
________________________________________________
Signature of Patient, guardian, or authorized representative
________________________
Relationship to Patient
For Office Use Only: ________________________
_____________
Witness’s Signature
Acct #
Date
____/____/____
THIS FORM WILL EXPIRE 30 DAYS FROM THE DATE OF SIGNING