Name: Preferred Family Medicine: Dr. Highley & Dr. Scullion
Address: 10627 Professional Circle, Suite A, Reno, NV, 89521

Name*
First Middle Last
Date of Birth*
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Day
Year
Address*
Street Address Address Line 2 City State ZIP Code

Enter your mailing address
Phone
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I authorize Christopher C. Highley D.O., Preferred Family Medicine, to obtain Protected Health Information from the following health care provider.*
- Yes
- No
Records to be sent to: Preferred Family Medicine, 10627 Professional Circle, Suite A, Reno, NV 89521 PHONE: (775)-204-0150 FAX: 775-501-6360
Name of Health Care Provider Requesting Records FROM:*

e.g. "Dr John Doe", "General Hospital", or "ABC Assisted Living", etc.
Address of Health Care Provider Requesting Records FROM:*
Street Address Address Line 2 City State ZIP Code
Health Care Provider Contact Phone
If you know it, please provide the health care provider's phone number.
Health Care Provider Fax Number
If you know it, please provider the Health care provider's fax number. If not, we will obtain it.
Information to be obtained:*
- Entire Record
- Discharge Summary
- History & Physical
- X-Ray Reports
- Lab Results
- Consultations
- Physician/Provider Progress Notes
- Allergy List
- Medication List
- Immunization Records
- Problem List
From: (date)
Month
Day
Year

Obtain records FROM this date.
To: (date)
Month
Day
Year

Obtain records TO this date.
Purpose for Need of Disclosure*
- Further Medical Care
- Insurance Eligibility/Benefits
- Legal Investigation or Action
- Personal
- Changing Physicians
(Select all that apply)
Regarding Mental Health: 1) Copies of medical records pertaining to diagnosis and/or treatment of psychiatric, psychological conditions and/or drug or alcohol abuse may be released to the recipient as noted above. 2) Copies of medical records, including information of the diagnosis and/or treatment for AIDS/HIV (including testing) may be released to the recipient as noted above.
I understand that if the person(s) and/or organization(s) listed above are not health care providers, health plans, or health care clearinghouses, who must follow the federal privacy standards, the health information disclosed as a result of this authorization may no longer be protected by the federal privacy standards and my health information may be redisclosed without obtaining my authorization.
Your Rights with Respect to This Authorization: · Right to Receive Copy of This Authorization- I understand that if I agree to sign this authorization, which I am not required to do, I must be provided with a signed copy of the form. · Right to Refuse to Sign This Authorization- I understand that I am under no obligation to sign this form and that the person(s) and/or organization(s) listed above who I am authorizing to use and/or disclose my information may not condition treatment or payment, on my decision to sign this authorization. · Right to Withdraw This Authorization- I understand written notification is necessary to cancel this authorization. To obtain information on how to withdraw my authorization or to receive a copy of my withdrawal, I may contact the Director of Health Information Management at (775) 204-0150. I am aware that the revocation will not apply to information that has already been released in response to this authorization.
If I fail to specify an expiration date or event, this authorization will expire 90 days from the date on which it was signed. I have had an opportunity to review and understand the content of this authorization form. By signing this authorization, I am confirming that it accurately reflects my wishes.
Authorization Expiration Date (Optional)
Month
Day
Year
Is form being signed by a person other than the patient?*
- No
- Yes
Signature of Patient
Date of Signature
MM slash DD slash YYYY
Patient is:
- Minor
- Incompetent
- Disabled
- Deceased
Please Specify Your Legal Authority
- Custodial Parent
- Legal Guardian
- Executor of Estate of Deceased
- Power of Attorney for Healthcare
- Authorized Legal Representative
Name of Person Signing Form:
Signature of Witness
Date of Witness Signature
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Request Medical Records