Authorization to Release Medical Information

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Patient Name:

DOB:

Medical Record #

Address

Telephone #:

E-mail Address and/or Fax #:

Physician / Healthcare provider Releasing Records

Who are the records being disclosed to?

Phone Number

Address

City

State

Zip Code

Dates of Services being Requested

Other Specified

Entire Medical Record for specified date(s) of service

Date(s) Specified for above

Information to be released by

Paper
CD/DVD
Secure E-mail

(Please note: release method availabilities vary by Facility locations; some options may be unavailable.)

List any restrictions

I understand that information disclosed pursiant to this authorization may include information relating to the following*. unless specifically restricted below: - Psychological / psychiatric conditon - HIV/AIDS diagnosis and/or testing - Genetic Testing - Drug and.or alcohol abuse diagnosis and/or treatment - Sexually transmitted disease(s) diagnosis and/or testing ***Please note: per State regulations, additional authorization may be required for certain conditions

The purpose of this disclosure is?

Redisclosure of Information: I understand that once information is disclosed pursuant to this authorization that the Health Insurance Portability and Accountability Act of 1996 (HIPAA), 45 C.F.R. Parts 160 and 164, protecting health information may not apply to the recipient of the information and, therefore, may not prohibit the recipient from re-disclosing it. Other laws, however, may prohibit redisclosure. Right to Refuse to Sign this Authorization: I understand that generally the person(s) and/or organization(s) listed above who I am authorizing to use and/or discuss my information may not condition my treatment, payment, or eligibility for health care benefits on my decision to sign this authorization Right to Revoke: I understand that I may revoke this authorization in writing at any time except to the extent that action has been taken in reliance on it, or unless this authorization is given as a condition of obtaining health insurance coverage and the insurer has a legal right to contest the policy or a claim under the policy. To revoke this authorization, I will provide the Privacy Officer at the above listed physician/health care provider’s office with a written revocation. Right to Inspect: I understand that I have the right to inspect and/or receive a copy of the health information I have authorized to be used or disclosed and that I may be charged and reasonable fee for any copies of the medical records that I receive.

Expiration Date

This authorization is in effect until ___________ (I understand that unless I provide a written revocation at an earlier date, this authorization will expire in one year.)

Signature of Patient or Legal Representative(s)

(Note: If patient is a minor child, both parents may be required to sign

Signature of Guardian

If required

Date:

Printed Name(s)

if signed by other than patient

Printed Name

Secondary (if required) if signed by other than patient

Relationship to Patient