AUTHORIZATION TO DISCLOSE PROTECTED HEALTH INFORMATION

(RELEASE FORM MUST BE COMPLETED IN ORDER TO BE VALID)

Patient Name: ______________________________________ DOB: _______________ SSN: _____________________

Address: ________________________________________________ Telephone No._____________________________

Name of Facility or Physician Authorized to Release: ___________________________________________

Address: _____________________________________________________ Telephone #. _________________

Name of Facility or Person Authorized to Receive: ____________________________________________

Address: _______________________________________________________ Telephone # __________________

INFORMATION TO BE RELEASED (Please be as specific as possible and limit information to only that which is absolutely necessary)

____ Progress Notes ____ Laboratory Reports ______ Radiology Reports ______ X-ray Films

____ Billing Statements ____ Others (Specify) ___________________________

SPECIFIC DATES OF SERVICE / TREATMENT NEEDED: FROM: ______________ TO: ________________

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, psychiatric health services, treatment for alcohol and drug abuse, domestic and physical abuse.

REASONS FOR DISCLOSURE:

____ Continuity of Care _____ Physician Change ____ Insurance Eligibility/Benefits

____ Legal _____ Personal ____ Others __________________

I understand I have the right to revoke this authorization at any time. I understand if I revoke this authorization I must do so in writing and present my written revocation to the facilities health information department. I understand that the revocation will not apply to information that has already been released in response to this Authorization. Unless otherwise revoked, this authorization will expire in 90 days.

I understand that authorizing the disclosure of this health information is voluntary. I can refuse to sign this authorization. Treatment, payment, enrollment or eligibility for benefits may not be conditioned on obtaining an authorization if the Health Information Portability Accountability Act prohibits such conditioning. If conditioning is permitted, refusal to sign the authorization may result in denial of coverage. I understand I may inspect or copy the information to be used or disclosed, as provided in CFR 164.524. I understand any disclosure of information carries with it the potential for an unauthorized re-disclosure and the information may not be protected by federal confidentiality rules. If I have questions about disclosure of my health information, I can contact (facility HIM director, privacy officer, or other office or individual’s name or contact information). By signing below, I am certifying my agreement, which the statement made in this form and agreeing to the release of my protected health information as indicated by this form

______________________________ ________________________

Signature of Patient Date

______________________________ ________________________

If Signed by Legal Representative, Relationship to Patient Signature of Witness

___________________________________ ________________________
If Signed by Legal Representative, Relationship to Patient Signature of Witness