Medical Records Release Form

Would you authorize Seema Kazi, MD dba Rise Well Behavioral to “Release” your complete medical records, including mental health information, to other individuals, healthcare providers, or entities involved in your care?*

Yes

Thank You very much.
There is no medical information to Release at this time. Please Click the button below to proceed to home page. Thank you.
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The medical record information release (HIPAA) form allows a patient to give authorization to a 3rd party to access their health records. The release also allows the added option for healthcare providers to share information. A medical release form can be revoked or reassigned at any time by the patient if a request is received to the clinic from the patient in writing.
The provider must approve the request before the records may be released and the provider reserves the right to deny a self-medical records request.
There’s no charge if the Medical Records are to be sent electronically to another Medical Entity.
For Medical Records mailed in Paper Format, there’s a $25.00 charge for the first 20 pages and $0.50 per page for each additional page plus powww.
When Medical Records are being sent to a non-Medical Entity in Electronic Format, there’s a $25.00 charge for the first 500 pages and $50.00 for more than 500 pages.
There is a $15.00 charge for affidavit requests.
Please allow 5 business days to process the request.
You can submit the request using the form provided below or by faxing the request to (817)-985-9390
For questions and/or concerns about the Medical Records Request, please send an e-mail at [email protected] or call (817)-369-9490
You are required to sign the “Authorization to Release Healthcare Information” before Rise Well Behavioral can fulfill your Medical Record request.

I Agree

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Date Of Birth*

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Date Of Birth

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Date

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Date

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Age*

Email Address*

Patient's Last Name*

Gender

Date Of Birth*

We apologize for the inconvenience, we only see patients 16 years of age or older.

Cell#*

Home#

Who is receiving Medical Records ?*

Reason*

Provider's Name*

Entity Name

Phone Number*

Fax #*

Address

City*

Provider State*

ZIP Code

Do you want an additional person and/or Medical Entity to receive your Personal Healthcare Information from Rise Well Behavioral?*

Yes

Who is receiving Medical Records ?*

Reason*

Provider's Name*

Entity Name

Phone Number*

Fax #*

Address

City*

Provider State*

ZIP Code

Do you want an additional person and/or Medical Entity to receive your Personal Healthcare Information from Rise Well Behavioral?*

Yes

Who is receiving Medical Records ?*

Reason*

Provider's Name*

Entity Name

Phone Number*

Fax #*

Address

City*

Provider State*

ZIP Code

Do you want an additional person and/or Medical Entity to receive your Personal Healthcare Information from Rise Well Behavioral?*

Yes

Who is receiving Medical Records ?*

Reason*

Provider's Name*

Entity Name

Phone Number*

Fax #*

Address

City*

Provider State*

ZIP Code*

Do you want an additional person and/or Medical Entity to receive your Personal Healthcare Information from Rise Well Behavioral?*

Yes

Who is receiving Medical Records ?*

Reason*

Provider's Name*

Entity Name

Phone Number*

Fax #*

Address

City*

Provider State*

ZIP Code*

Thank you very much.
Please acknowledge the consent before you Sign and Submit. Thank you !

This is an authorization of your medical information to be transferred between health care providers, health insurance companies and any other party involved in my medical care.

I hereby authorize the following facilities/hospitals and doctor(s) to release all Personal Healthcare Information to Seema Kazi, MD dba Rise Well Behavioral for treatment consultation and to better manage my health.

This request includes mental health progress notes, hospital summaries, echocardiogram reports, cardiac catheterization reports, laboratory reports, electrocardiograms, physician progress notes, labs, and any other healthcare information relating to my condition.

I have the right to revoke this authorization at any time by sending and/or giving a written notice to Rise Well Behavioral. This authorization is valid indefinitely until I revoke this authorization in writing.

I understand and agree that I have the right to revoke this authorization anytime by sending/giving a written notice to Mid Cities Psychiatry And until I revoke this authorization in writing, this authorization is valid indefinitely. -1*

I Agree

Signature*

You are all set.
We'll reach out to you if we have any additional questions.
In the meantime, please do not hesitate to contact us at (817)-369-9490 or e-mail us at [email protected].
Sincerely,
Rise Well Behavioral

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