Medical Records Release

If you would rather fill out the PDF form and print it out to bring in with you, please download below.

Authorization for the Use and Disclosure of Protected Health Information

This authorization is required by the Health Insurance Portability and Accountability Act of 1996 to inform you of your rights to privacy with respect to your health care information.

Patient Name *

First

Last

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Date of Birth *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Reason/Information for Release *

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Information to be released *

All records
Only records listed below (box will appear when this is checked):

Please select the following *

Send my OGGI records to the recipient I list
I authorize OGGI to receive my records from who I list
Send my OGGI records to recipient email I list

Recipient Name *

First

Last

Recipient Email

Recipient Address *

Address Line 1

Address Line 2

City

State

Zip Code

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Phone Number *

Fax Number *

By checking this box and signing below, I agree to the following terms and conditions *

I agree

I give permission to OGGI to release all records containing in my chart from Ohio Gastroenterology Group, Inc. including records received from other physicians or entities. I understand that the information in my health record may include information relating to sexually transmitted disease, acquired immunodeficiency syndrome (AIDS) or human immunodeficiency virus (HIV). It may also include information about behavioral or mental health services and treatment for alcohol and drug abuse. I understand that by disclosing these records, the practice cannot guarantee the recipient will not re-disclose or use the records in a way that violates the privacy rules. Under the privacy rules, I have the right to revoke this authorization at any time in writing, and OGGI must cease using this authorization. However, the practice may complete any actions initiated with my PHI prior to my revocation which rely on the above records for completion. (An example of this would be that your insurance coverage may rely on these records to contest a claim). I must revoke this authorization in writing to: Ohio Gastroenterology Group, Inc. ATTN: Privacy/Security Board 3400 Olentangy River Road Columbus, Ohio 43202

Name *

First

Last

Relationship to patient (if signing as guardian)

Today's Date *

After clicking “Submit”, please wait a few seconds for the confirmation page to appear.