Form No.

296

Columbia Addictions Center

5570 Sterrett Place, Suite 205
Columbia, MD 21044
Tel: 410-730-1333
Fax: 410-730-1559

AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS

Patients Name: ______________________________________

DOB: __________

Name of Current Provider: ______________________________________

Name of Receiving Provider: ________________________________
Organization/Medical Group: ________________________________
Address:

________________________________

Email: _______________________

________________________________

Phone: _______________________

________________________________

Fax:

_______________________

Action Requested:
_____ Release my medical records to the provider listed above
_____ Discuss my medical records with the provider listed above
_____ Obtain copies of my medical record from the provider listed above
By signing this form, you authorize the release of your medical record as stipulated above and
agree to pay fees compliant with the Maryland Department of Health and Mental Hygiene.
Patients Signature:

__________________________________________

Date of Request:

__________________________________________

FOR OFFICE USE ONLY:

$23.34 processing fee

$5.75 USPS flat rate shipping
$0.76 per page ( x ______ )

Request Date:

TOTAL FEE:

Date Released:

___________

Initials:

___________

$_______

Payment Amount and Method:

___________

Release By:
___________
(must be within 21 business days of request)