Record Release Request

Metamorphosis LTD

Authorization to Release Medical Records to Metamorphosis LTD

I hereby authorize , located at , to release my Medical Records and/or MRI Imaging records to Metamorphosis LTD. 

Patient’s Name: Phone number: Address: Date of birth:

Medical Records are to be sent to: Metamorphosis LTD, 113 Latigo Lane Suite D, Canon City, CO 81212

Fax Number records to be faxed to: 888-965-6893

I understand that this information shall be in effect for 180 days following the date of signature. Further, I may revoke this authorization at any time by giving oral or written notice to Metamorphosis. A photocopy of this authorization shall constitute a valid authorization. I realize once my medical records have been released to Metamorphosis, my revocation cannot be effective to the extent which the healthcare provider has taken the action with the reliance of this Authorization. I understand that the health information I am authorizing may disclose additional information regarding drug or alcohol abuse or psychiatric illness, and records of testing, diagnosis or treatment for HIV, HIV-related diseases and communicable disease-related information. I understand that Metamorphosis may not condition treatment, payment, enrollment, or eligibility for benefits on whether I sign this authorization. I have read this Authorization and I acknowledge being familiar and fully understand it’s terms and conditions.

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Signature Certificate
Document name: Record Release Request
Unique Document ID: c09977277f02b4a79d83389a5cd909edcd8b56f2
Timestamp Audit
2017-05-14 09:48:33 MDTRecord Release Request Uploaded by Lisa Pearson - IP