Record Release from Frontier Family Practice

The document titled “Record Release from Frontier Family Practice” is an authorization form for the release of medical information from Frontier Family Practice. It requires the patient’s full name, date of birth, address, phone number, and the date by which the records are needed. The form allows patients to specify the mode of record delivery (mail, pickup, fax) and the type of information requested, such as progress notes, hospital records, X-rays, among others. It emphasizes the inclusion of all health care information in the patient’s care, including sensitive data related to mental health, drug or alcohol use, and sexually transmitted diseases. The authorization is valid for six months unless revoked earlier, with a clear mention of the process for revocation in accordance with Montana State Statute. The form concludes with spaces for patient and guardian signatures, indicating consent to the release of the specified medical records.