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Patient Albuquerque, NM 87109 We are not able

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ROID0021 (Rev 08/04/20)
Page 1 of 2
We are not able to process incomplete authorizations. To prevent delays in processing this request
please complete all sections of the authorization. Incomplete authorizations will be returned.
Patient
Information
Patient Name
Address
City/State/Zip
Phone #
Date of Birth
RELEASING
Facility
Facility Name
Address
City/State/Zip
Phone #
Fax #
If you need information from another Lovelace
facility, please specify which facility below:
Receiving
Facility/
Individual(s)
Name
Address
City/State/Zip
Phone #
Fax #
Lovelace Medical Group
Information to be: Mailed to above address Picked up Call # above when ready for pickup Fax to above #
Billing Records
Consultation
Discharge Summary
EKG's
Emergency Records
List specific
description of
Information to
be released
The requested information will be used for the following purpose(s):
Continuity of Care Disability Determination Insurance Legal Personal Use
Facesheet
History & Physical
X-Ray/Imaging Reports
X-Ray/Imaging Films/CD
Laboratory
Progress Notes
Therapy Records
All Records
Other:
Behavioral Health Records,
HIV, STD
If these types of records are being requested, patient must sign below authorizing release.
Behavioral Health Records
HIV Records
STD Records
Alcohol/Drug Treatment Records
Date(s) of Service Requested: From To
Patient or Legal Representative Signature Required:
Request for Electronic
Records
(Lovelace Medical Center, Westside
& Women's only)
I would like to request an electronic copy of my discharge instructions.
RELEASE OF INFORMATION
AUTHORIZATION/REQUEST
Medication Records
Nursing Records
Operative Report
Pathology Report
Physician Orders
I would like to request an electronic copy of my patient health information as defined
here (including test results, problems, medications, allergies, discharge summary,
and procedures). I understand the facility has three business days to provide this
copy.
Lovelace Medical Group
6701 Jefferson NE
Albuquerque, NM 87109
6701 Jefferson NE
Albuquerque, NM 87109
505-727-8197
505-727-9501 - Routine
ROID0021 (Rev 08/04/20)
Page 2 of 2
Date
Signature of patient or patient's legal representative
Relationship to patient or representative's
authority to act for the patient, if applicable
Printed name of patient or patient's legal representative
• I understand that I may revoke this authorization at any time by notifying the facility releasing records in writing to the
Lovelace Health System, except to the extent that; action has been taken in reliance on this authorization; or
if this authorization is obtained as a condition of obtaining insurance coverage, other law provides the insurer with the
right to contest a claim under the policy or the policy itself.
• I understand that the information I authorize a person or entity to receive may be re-disclosed and no longer protected
by federal privacy regulations.
• This authorization shall be in force and effective for one year from the date of signing or until ,
at which time this authorization to disclose this protected health information expires.
• The person/organization authorized to use/disclose the information will receive compensation for doing so.
Yes No
• I understand that this authorization is voluntary and that I may refuse to sign this authorization. My refusal to sign will
not affect my eligibility for benefits or enrollment, payment for our coverage of services, or ability to obtain treatment,
except as provided under the NOTES listed at the bottom of this form.
NOTE: If the purpose of this authorization is for the use and/or disclosure of health information for a research study, and I
refuse to sign this authorization, Lovelace Health System reserves the right to deny treatment associated with such
research.
NOTE: If the purpose of this authorization is to disclose health information to another party based on health care that is
provided solely to obtain such information, and I refuse to sign this authorization, Lovelace Health System reserves the
right to deny that health care.
A copy of this signed form will be provided to the patient.
For Office Use Only:
ID Verified Yes No
Type of ID P'd Driver's License Military School Other
Verified by
Employee Name Date
NOTE: Lovelace Health System recognizes a patient's rights under HIPPA to access copies of his/her health information.
There may be charges associated with processing a request and producing requested records.
RELEASE OF INFORMATION
AUTHORIZATION/REQUEST
Lovelace Medical Group
6701 Jefferson NE
Albuquerque, NM 87109
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Completed 3 March 2021

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