2301 House Avenue • Suite 400 • Cheyenne, WY 82001• (307) 634-5216 • Fax #: (307) 773-0795 Request For Release Of Medical Records I hereby Request and Authorize the use and/or disclosure of Medical Records pertaining to: All Records generated at Cheyenne OB/GYN except Sexually Transmitted Diseases (STD) and psychological (mental Health) records. STD’s Including HIV and AIDS Psychological Records Specific Information ________________________ _____________________________________________________________ Print Full Legal Name of Patient ___________________ Date of Birth _____________________________________________________________ Other Names Used ___________________ Social Security Number Obtain Records From: Name: ____________________________________________________________________ Address: ____________________________________________________________________ (Street) (City) (State) (ZIP) Reason for Request of Records: ___________________________________________________ Patient Will Pick Up -Or- Send Records To: Name: ______________________________________________________________________ Address: ____________________________________________________________________ (Street) (City) (State) (ZIP) Please allow 2 weeks to process your records request _____________________________________________________________________ SIGNATURE of Patient Parent Legal Guardian Address: ______________________________________________________________________________ (Street) (City) (State) (ZIP) Phone: (_____)__________________ Date: ____________________ Witness: _________________________________________ All information released to or obtained from this facility will be used for the purpose of evaluation of medical status of this patient. Information released to us will not be further transferred from this facility without additional patient authorization. Authorization for the release of this patient’s records may be withdrawn at any time. All medical records will be copied for the patient free of charge the first time. A fee will be assessed accordingly for any additional copies. Records released by: ______________ Records sent out by: ___________ on _________ Rev. 12/12 (MLP)