Request/ Release of Medical Records
379 N. 500 W. STE 1A
Vernal, UT 84078
Phone: (435) 789-1165
Fax: (435) 789-1169

I authorize Basin Clinic to: (please check one)

Release Medical Records to: Request Medical Records From:
Name of Physician / Organization
Complete Address (REQUIRED)
Reason for Request
Record Dates for Copying
I understand my rights under HIPPA guidelines, and that the information to be released may contain information regarding:
  • Drug or Alcohol Abuse, if any.
  • Psychological or Psychiatric Conditions, if any.
  • A Diagnosis for or other reference to Acquired Immune Deficiency Syndrome (AIDS).
  • I understand that I may be charged for records copied.
    By signing I free providers of Basin Clinic from any legal liability that may arise from the release of information.
    This authorization is valid for 60 days from the date signed.
    Name of Patient(s)
    Social Security # Birth Date
    Patients Address Phone #
           
    Signature of Parent or Guardian _______________________________________________________
    Relationship Date ________________
       
    Witness Signature ____________________ Date ________________