PATIENT INFORMATION

Name (First, Middle, Last)

Current Address

City

State

Zip

Last 4 Digits Social Security #

Email

Phone Number

Date of Birth

Cleveland Clinic Akron General Medical Record # if known

RECIPIENT INFORMATION

Name of Recipient

Address

City

State

Zip

Phone Number

Fax Number

Email

Check delivery option desired:

Release Information to MyChart Account (large requests over 50 pages will be delivered via alternate option selected below)

Paper

Secure electronic delivery (provide recipient's email)

RELEASE INFORMATION

Release Information From (check all that apply)

Cleveland Clinic Akron General OR Specify Cleveland Clinic Facility

Purpose for Disclosure

Dates of Service to Release (FROM)

(TO)

DISCLOSURES

For itemized billing, please visit https://www.gethospitalbill.com or please call, 866-621-6385.

I, the undersigned, authorize Cleveland Clinic Akron General to release health information as indicated/described above. I understand and acknowledge that the requested health information may contain information regarding physical and mental illness, HIV test results or diagnosis, treatment of AIDS/AIDS- related conditions and/or alcohol/drug abuse. *This authorization does not include permission to release outpatient Psychotherapy Notes as defined below. *Release of Psychotherapy Notes requires a separate authorization.

This authorization and consent will expire one year from the date of authorization written below, unless revoked by me (or my legal representative) through written notice presented to Health Information Management (see contact information below). Any revocation will not apply to information that has already been released in response to this authorization. I understand that treatment, payment, enrollment or eligibility for benefits will not be based on whether or not I sign this authorization.

After my health information is released, my information may be re-disclosed by the recipient and may no longer be protected by law. The recipient of my health information may be charged for the service for releasing medical information. There is no charge to send records directly to my health care provider.

If Authorization is not complete, signed and dated, it may be returned and result in my information not being released until completed.

Name of Patient / Patient's Representative

Relationship, if not patient

I have reviewed and acknowledge and consent to the terms described above. I confirm that I am the patient named above (or if the patient is a minor child, the patient's parent or legal guardian named above) and I understand and agree that by clicking the box below, I am electronically signing this Authorization to Disclose Health Information form and an electronic signature has the same effect as my written signature.

Click Here to Confirm and Sign.

*Psychotherapy Notes are defined as notes that document private, joint, group, or family counseling sessions that are separated from the result of a patient's medical records.
**If other than the patient's signature, a copy of legal paperwork verifying the patient's personal representative MUST accompany the request (e.g., court appointed guardian, durable power of attorney for health care). Exception: parent signing for a patient under the age of eighteen.
**For a deceased patient, a court entry or order appointing a fiduciary, executor, or administrator, or letters of appointment received from Probate Court must accompany an authorization signed by the named individual. If the estate has not been probated, a death certificate is required to be submitted with the documents naming the administrator or executor of the estate.

For any requests that require additional documents, Click here to access the PDF form. It wil have instructions on how to submit the form with your attachments.