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Please print out this form, complete it and
return it to our office.
AUTHORIZATION FOR RELEASE, USE AND DISCLOSURE OF
HEALTH INFORMATION
Patient Name:
________________________________________ Date of
Birth: ________________
Address:
_________________________________________________________________________
Phone
Number:________________________________________Fax
Number:_________________
Access Request to
Copy/Inspect
I authorize
the use/disclosure of health information about
me as described below:
1.
The following organization is authorized
to make the disclosure:
_________________________________________________________
Name of Facility
__________________________________________________________
Address
2.
The type of
information to be used or disclosed is as
follows (please include dates of service)
Date(s)
of Service:
______________________________________________________________
Complete Medical
Record
Abstract of Medical Record (H&P, Discharge
Summary,
Consultation Reports, Operative & Procedure
Reports, EKGs,
Laboratory, X-ray and imaging reports)
History & Physical
(H&P)
X-ray and imaging reports
Discharge
Summary
Progress Notes
 Operative
Report
 Laboratory
Test Results
Consultation
Reports
Immunization Record
Other- list specific
Items:_______________________________________
Behavioral Health Reports:
Social
History
Treatment Plan
Client Data
Form
Academic History
Referral/Treatment
Form
Aftercare Instructions
Admission
Evaluation
Psychological Evaluation
Notification of Admission
Other – list specific items:
_______________________________________
3. I understand that the information in my
health record may include information relating
to sexually transmitted disease, acquired
immunodeficiency syndrome (AIDS), or human
immunodeficiency virus (HIV). It may also
include information about behavioral or mental
health services, and treatment of alcohol abuse.
This information is being
provided to you from records whose
confidentiality may be protected by State and/or
Federal law.
4. I understand that your
facility may receive compensation for medical
record copying in accordance with State law.
5. This information may be disclosed to and
used by the following individual/organization:
Name:
________________________________________________________________________
Address:
_______________________________________________________________________
For the purpose of:
Further Medical Care
Insurance Eligibility/Benefits
Inspection/Copying of my records
Legal Investigation or Action
Personal
Changing Physicians
Other (please
specify):_______________________________________
6. I understand
I have the right to inspect and obtain a copy of
my protected health information in the
designated record sets you or your business
associates maintain. I understand however I am
not entitled to inspect or obtain a copy of any
psychotherapy notes or any information compiled
in anticipation of use of or for any civil,
criminal or administrative action or proceeding,
any information not subject to disclosure under
the Clinical Laboratory Improvements Amendments
of 1988, (42 U.S.C. section 263 (a), and certain
other records.
7. I understand
that I may refuse to sign this authorization and
that my refusal to sign will not affect my
ability to obtain treatment or payment or my
eligibility for benefits. I may inspect or copy
any information used or disclosed under this
authorization as described in #7 above.
8. I understand
that the information disclosed pursuant to this
authorization may be subject to re-disclosure by
the recipient and no longer be protected under
the terms of this authorization.
9. I
understand that I may revoke this authorization
in writing at any time. To understand that if I
revoke this authorization, I must do so in
writing and present my written revocation to the
Health Information Management Department. I
understand that the revocation will not apply to
information that has already been released in
response to this authorization. This
authorization expires within 90 days, unless
otherwise specified.
.__________________________________________________
__________________________
Signature of
Patient
Date
(If signed by person
other than the patient, state relationship and
authority to do so.)
.__________________________________________________
Name of Patient (Please
Print)
Patient is:
Minor
Incompetent
Disabled
Deceased
Legal Authority:
Custodial Parent
Legal Guardian
Executor of Estate of Deceased
Power of Attorney for Health
Care
Authorized Legal Personal Representative
._________________________________________________
.___________________________
Signature of
Witness
Date
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