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Medical Record Release Form - Motorola Solutions Mobile App

This form allows patients to authorize health care providers to disclose their protected health information. Designed specially for the Inova Health System, the form features sections that allow users to enter the basic patient data, what information to release, the purpose of the release, the record status and the patient's signature. This app works on a variety of Motorola Solutions devices, including the ES400 and ET1.

  • Lendlease
  • The Cooperative
  • PG&E
  • oxy
  • Red Bull
  • Mirvac

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Take a peek inside the Medical Record Release Form - Motorola Solutions Mobile App

Included Features

Our App Builder gives you the power to easily add and remove the ones you want. {{controller.show_all ? 'See included features.' : 'See more features.'}}

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Included Fields

Customize to add, remove, or edit any of the fields below.

  • Ico statictext

    INOVA Health System - Authorization to release/disclose protected health information

  • Ico textbox

    Patient Name

  • Ico textbox

    Medical Record Number

  • Ico textbox

    Social Security (optional)

  • Ico date

    Patient Date of Birth

  • Ico textbox

    Dates of Services

  • Ico textbox

    Contact Phone Number

  • Ico statictext

    Patient Address

  • Ico textbox

    Street Address

  • Ico textbox

    City

  • Ico textbox

    State

  • Ico integer

    Zip code

  • Ico statictext

    I authorize this Hospital

  • Ico statictext

    to release or disclose the following information to:

  • Ico textbox

    (Name of person to receive information)

  • Ico textbox

    Physician Phone #

  • Ico textbox

    Physician Fax #

  • Ico textbox

    Street Address

  • Ico textbox

    City

  • Ico textbox

    State

  • Ico integer

    Zip

  • Ico statictext

    Information to be released/disclosed

  • Ico statictext

    Check all that apply:

  • Ico checkbox

    Emergency room record

  • Ico checkbox

    Face Sheet

  • Ico checkbox

    Discharge Summary

  • Ico checkbox

    History and Physical

  • Ico checkbox

    Consultation

  • ...and More!

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