Release Authorizations

If you’ve been asked to submit an information release, this page will guide you through the process. We offer three forms:

1. Authorize us to request your information – This form allows us to obtain your medical records from other healthcare providers where you’ve received care, helping us better understand your treatment history before your upcoming visit.
2. Authorize us to share your medical records – This form gives us permission to share your medical information with another healthcare organization to support their involvement in your care or to provide feedback on your treatment.
3. Authorize us to discuss your care – This form allows us to communicate with others about aspects of your care that are typically confidential

Follow the instructions below and we will walk you through the process. It is possible to fill out more than one form at once and have them sent to our team.

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Information Release Authorizations

Which authorization(s) would you like to grant?

Authorize us to request your health information from others.

Authorize us to provide your health information to others.

Authorize us to talk about your health information.

Who is authorizing and signing these requests? *

Patient

Spouse of Deceased

Legal Guardian

Executor of Estate

Health Care Power of Attorney

By submitting this request, I certify that I am authorized under HIPAA to request this information and understand my electronic signature is legally binding; and release New England Cancer Specialists from all liability related to the disclosure of records as requested.

Your Name

Your Name

First Name

First Name

Last Name

Last Name

Patient Name *

Patient Name

First Name

First Name

Last Name

Last Name

Maiden Name

Patient Date of Birth *

Patient Phone *

Phone type: *

Cell

Home

Work

OtherOther

Patient Email

If unable to reach me: *

You may leave a message on the number indicated above.

I do not want messages left on the number indicated above.

OtherOther

Authorization to Request Your Information

I authorize New England Cancer specialists to obtain my medical records from other healthcare providers for the purpose of providing medical care to me, and to disclose it to: *

New England Cancer Specialists, 2 Independence Dr., Kennebunk, ME 04043. Phone: 207-303-3300 Fax: 207-985-9820

New England Cancer Specialists, 155 Borthwick Ave East, Suite 303, Portsmouth, NH, 03801. Phone: 207-828-0100 Fax: 603-828-0111

New England Cancer Specialists, 11 Rock Row, Suite 310, Westbrook, ME 04092. Phone: 207-303-3300 Fax: 207-396-7610

New England Cancer Specialists, 105 Topsham Fair Mall Rd, Topsham, ME 04086. Phone: 207-303-3300 Fax: 207-729-2789

Authorization to Release Your Medical Records to an Outside Entity

How should we send records? *

Mail

Fax

Name of Healthcare provider, physician, or facility to release to? *

Address *

Address

Address

Address

City

City

State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

State/Province

Zip/Postal

Zip/Postal

Email *

Fax *

What information would you like shared? *

Complete medical records including records from prior providers.

Only medical records from New England Cancer Specialists.

Only immunization records.

Authorization to Discuss Your Information

Who would you like us to discuss your information with? *

I will tell you who you can discuss my care with.

I do not want information discussed with anyone.

I understand this release will remain in effect until terminated by me in writing. *

Yes

Authorized People to Discuss Care With

Name

Name

First Name

First Name

Last Name

Last Name

Phone

Contact Type

Spouse

Partner

Emergency Contact

Family

OtherOther

Add Remove

Risk of Re-disclosure *

I understand that once this information is released, my physician and/or their employees cannot prevent the re-disclosure of that information. I release New England Cancer Specialists and any of its employees from any and all liability arising directly from disclosure authorized by this consent and any re-disclosure of that information.

Revocation *

I understand I have the right to revoke this authorization at any time. Authorization will be considered inactive when New England Cancer Specialists receives a request in writing to revoke the authorization.

I understand and release the following sensitive information: *

Alcohol or drug dependency records.

HIV / AIDS Antibody Test Results, Diagnosis, and Treatment Records.

Mental Health Treatment Records - Specific Diagnosis.

Genetic Information Including Test Results.

Would you like us to release your full history or only records for a certain time frame? *

All Records

Records between certain dates.

Earliest date we should include. *

Latest date we should include. *

I understand that my release to share information with those I identified above, will remain in effect for one year from the date signed. *

Yes

Signature of Patient *

Clear

Signature of Legal Representative *

Clear

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