Authorization For Use Or Disclosure Of Health Information

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Completion of this document authorizes the disclosure and/or use of health information, about you.
Failure to provide all information requested may invalidate this Authorization.
Name of Patient: _________________________________________________________________________
Date of Birth: ______________________________ SSN: ________________________________________
Patient Address: _________________________________________________________________________
City: ___________________________________________________ State: __________ Zip: ____________
Phone #: ________________________________________________________________________________
USE AND DISCLOSURE OF HEALTH INFORMATION
I hereby authorize ________________________________________________________________________
to release to: ________________________ Covering the period of healthcare from _______ to _____
Phone #: ________________________________________ Fax: ___________________________________
(Persons/Organizations authorized to receive the information) (Address - street, city, state, zip code
and/or fax number)
The following information:
a. F All health information pertaining to my medical history, mental or physical condition and
treatment received. - OR
F Only the following records or types of health information (including any dates):
F Discharge Summary
F Consultation(s)
F All pertinent Lab / X-rays / EKG
F History and Physical
F Operative Report
F Other: ______________________
F Rehab
F ER
b. I specifically authorize release of the following information (initial as appropriate):
______ Mental health treatment information
______ STD
______ HIV test results
______ Sexual Assault
______ Alcohol/drug treatment information
______ Child Abuse/Neglect
______ Outpatient psychotherapy notes
PURPOSE
Purpose of requested use or disclosure: F patient request; OR F other:
________________________________________________________________________________________
________________________________________________________________________________________
EXPIRATION
This authorization expires on: _____________________________________________________________
PLEASE CONTINUE ON NEXT PAGE
PATIENT I.D.
2 HIMROI
AUTHORIZATION FOR USE OR DISCLOSURE
OF HEALTH INFORMATION
Page 1 of 2
PHSI-280-014-AH (01/11)
ORIGINAL - CHART
CANARY - PATIENT

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