Locate us677 Cathedral Dr.
Rapid City, SD
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Main Clinic 605-343-9224
Appointments 605-342-6905

 
 

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Authorization for release of Medical Records

To print and complete, click here to download.

 

All information must be filled out for release to be valid.

Patient First Name M Initial Last
Patient Email
Patient Account # Date of Birth
Social Security # Current Phone #
Patient Address
City State Zip
Date needed by        
 
Release Medical Records from
Physician Clinic/Hospital
Address Phone
Fax
 
Release Medical Records to
Physician Clinic/Hospital
Address Phone
Fax
 
Purpose of releasing medical information
 
 

Black Hills Obstetrics & Gynecology LLP will release only medical information documented /dictated on treatment received at this facility. If you have been treated at another facility please contact them to make arrangements. I understand that this release of medical records may contain information regarding drug or alcohol abuse, mental health issues and/or HIV (AIDS) and STD (Sexually Transmitted Diseases)


Please send copy of records as indicated: All Records (Including but not limited to Mental Health, STD, HIV/AIDS, Alcohol/Drug, & Disability)

Or, select specific records as below:
Clinic Notes Mental Health   Pap/Birth Control   STD Records  
HIV/AIDS   Alcohol/Drugs   Prenatal   Immunizations  
Labs Mammo/Ultrasound   Other


Digital Signature: Type full name




Guardian or Legal Representative: Type full name


This authorization expires one year from the date of receipt unless revoked in writing prior to expiration date.