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Name*

First Last

Email*

Phone*

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Authorization for Release of Protected Health Information (PHI)

Thank you for reaching out to Datalink ITS to obtain access to your protected health information (PHI).

To ensure your privacy and security, please utilize the secure form below specifically designed for patients seeking their own medical records for personal use or continuing care needs. Simply fill out the form to request copies from our client’s medical facilities. Our team will process your request, and you can expect completion within 7-10 days.

Should you have any inquiries, feel free to reach out to Datalink at 888-997-7299 or via email at customerservice@datalinkits.com.

We appreciate your trust in Datalink ITS to complete your request.

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Release Form

Authorization for Release of Protected Health Information (PHI)

"*" indicates required fields

Step 1 of 6

16%

Before you proceed...

For the most cost-effective and efficient method to obtain or transfer your medical records, Datalink ITS suggests opting for an electronic copy (PDF) to be sent directly to yourself by selecting the "myself" option on the form. This grants you full control to possess a comprehensive set of your medical records, ready to be shared with medical providers and any other parties, without incurring future additional fees.

Patient Information

Patient Name*

First Middle Last

Patient Date of Birth

MM slash DD slash YYYY

Address

Street Address Address Line 2 City State ZIP Code

Phone*

Email Address*

Party Authorized to Disclose Protected Health Information

Who/Where are you requesting medical records FROM?

Physician Name:*

Medical Facility or Practice Name:*

Phone

City

State

Party Authorized to Receive Protected Health Information

Medical Records

Where would you like us to forward your medical records?*

Myself and/or

Another Medical Provider

Medical Provider Name

Name of Provider or Medical Facility

Medical Provider Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Medical Provider Phone

Medical Provider Fax

Medical Provider Email

Do you need to send to additional recipient ($25)?

Yes

Please enter the data for the second medical provider:

Additional Recipient

Name of Provider or Medical Facility

Additional Recipient Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Additional Recipient Phone

Additional Recipient Fax

Additional Recipient Email

Protected Health Information To Be Disclosed

Date Range of Information To Disclose

Any and All Dates of Service Available from First Seen to Most Recent

Specific Date Range

From Date

MM slash DD slash YYYY

To Date

MM slash DD slash YYYY

Type of PHI to be Disclosed:*

Any and All - No Restrictions

Any and All - With Restrictions

Comments

Please indicate what information you do not want disclosed here..

Legal Disclosures and Authorization

Purpose of Disclosure:

This Authorization will expire in:

Please acknowledge your understanding and acceptance by checking the following boxes: (All boxes must be checked)

Revoke*

I understand that I may revoke this authorization in writing at any time except to the extent that action has been taken in reliance upon this authorization (45CFR 164.508(c)(2)(1)). To revoke this authorization contact Datalink ITS at customerservice@datalinkits-com.preview-domain.com**

Treatment*

I understand that treatment or payment cannot be conditioned on my signing this authorization , except in certain circumstances such as for participation in research studies or programs, or authorization of the release of testing results for pre-employment purposes (45 CFR 164.508 (c)(2)(i)).**

Records*

I understand that my medical records are confidential and cannot be disclosed without my written authorization except when otherwise permitted by law. Information used or disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and may no longer be protected.**

Request*

I understand that my request will be processed pending confirmation of the patient’s identity and may require additional information.**

Information*

I understand that the specific information to be disclosed may include, but is not limited to: history , diagnosis, and or treatment of drug and/or alcohol abuse, mental illness, communicable disease, including Human Immunodeficiency Virus (HIV) and Acquired Immune Deficiency Syndrome (AIDS) (45 CFR 164.508(c)(2)(i)).**

Discount Code

Your Total Cost

Add-on: USB drive via First Class US Mail Quantity

Price: $10.00

Quantity

Payment Method

Credit Card

Electronic Check

Card Type

Name on Card:

Card Number:

Expiration Date:

CVC Code:

Billing Zip Code:

Type of Account:

Checking

Savings

Name on Account

Routing Number:

Account Number:

Payment Information

Name

First Last

Relationship to Patient:

Electronic Signature: Entering my full name in the field below indicates that I am the patient or the patient's duly authorized representative, that I agree to pay the fees related to this request, and that I authorize the release of my protected health information to the designated recipient.

Consent

I understand that checking this box constitutes a legal signature confirming that I am the patient or the patient’s duly authorized representative and acknowledge and agree to the disclosure of medical records and am responsible for payment of associated fees.

Additional documentation(s)

Drop files here or

Max. file size: 256 MB.

Additional comments:

Leading provider of scalable and customized health information management solutions to medical facilities throughout California.

Our Services

Release Of Information

Retiring Physicians

Storage and Retention

Relocation Support

Medical Practice Closure Support

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Release of Information

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Contact

Mailing Address
6285 East Spring Street #103
Long Beach, CA 90808

Address
3854 W Cerritos Ave,
Los Alamitos, CA 90720
(by appointment only)

Phone
(888) 997-7299

Email
info@datalinkits.com