Release Of Information Form - Unity Care Nw printable pdf download

1616 Cornwall Ave Ste 205

Bellingham WA 98225

Phone:

360.676.6177

Toll Free:

877.235.6850

Fax:

360.671.3574

AUTHORIZATION TO OBTAIN OR DISCLOSE HEALTH CARE INFORMATION

Patient Name

Date of Birth

Previous Name

SSN

Release records from:

Release records to

Facility/Name

Address

Phone:

Phone or Fax #

Phone or

Fax #

You may use or disclose the following health care information (check all that apply)



All health care information in my record, including testing and diagnosis for HIV, sexually transmitted

diseases, psychiatric disorders/mental health, drug and/or alcohol use. Send two years worth of records up to

and including the most recent dates of service.



Specific health care information in my record relating to the following treatment or dates:

_________________________________________________________________________________

Do NOT send records regarding (check any that apply):

 HIV/AIDS

 Sexually transmitted diseases

 Psychiatric disorders/mental health

 Drug and/or alcohol use

 Other _________________________

Reason (s) for this authorization (check all that apply)

 At Patient Request

 Mutual Exchange, no paper records needed at this time

 Patient Personal Use (a fee may be required)  Verbal Exchange of Information

 Transfer of Care / Continuity of Care

 Other (specify) _________________ Legal? Insurance?

This authorization ends (Please check ONE of the following options):

 in 90 days from the date signed

 one year from the date signed

 other: ________________________________________________________________

(No longer than one year from date signed)

Patient Notices

I understand that, if the recipient of the information disclosed under this authorization is not a health plan or provider covered by federal and state

privacy laws, the information may be re-disclosed by the recipient and no longer protected by those laws. If the information being disclosed under

this authorization includes HIV/AIDS, sexually transmitted diseases, mental health, genetic testing, and drug/alcohol abuse diagnosis, treatment or

referral information, federal law and regulation including 42 CFR Part 2 and 45 CFR Parts 160 and 164 or state law may prevent the recipient from

re-disclosing this information

I may refuse to sign this authorization. My refusal will not adversely affect my ability to receive treatment, to enroll in a health plan, to be eligible for

benefits, or to obtain payment for services unless this authorization is sought for purposes of research-related treatment, to determine my eligibility

or enrollment in a plan, for underwriting or risk determinations or if the services related to the information to be disclosed are performed solely for

the purpose of providing that information to someone else.

I may revoke this authorization at any time by notifying the Health Information Management/Medical Records Department of Unity Care NW.

However, any such revocation will not apply to any activity undertaken based on this authorization.

__________________________________________________________

_____________________________________

Patient or legally authorized individual signature

Date

__________________________________________________________

_____________________________________

Printed name if signed on behalf of the patient

Relationship

For Administrative Use Only