Authorization For Release Of Patient Records

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THE VALLEY HOSPITAL
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Doctor’s Appt date:_______________________
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Ridgewood, New Jersey
Time: ___________________ (when applicable)
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AUTHORIZATION FOR RELEASE OF PATIENT RECORDS & INFORMATION
I, ____________________________________________________________, born on ____________________________________
(Name of Patient)
(Date of Birth)
do hereby consent and authorize The Valley Hospital to disclose to:
_____________________________________________________ located at ____________________________________________
(Name of person*, Physician, or other Hospital/Rehab Facility)
(Address and Phone Number)
__________________________________________________________________________________________________________
the following type of information from the hospital records:
__________________________________________________________________________________________________________
and the purpose or need for this disclosure is ______________________________________________________________________
(Doctor’s appointment, personal use, etc.)
I understand that I have the right to revoke this Authorization at any time. I understand that in order to revoke this Authorization , I must
do so in writing and present my written revocation to the Privacy Officer at The Valley Hospital, 223 North Van Dien Avenue,
Ridgewood, N.J. 07450. I understand that the revocation will not apply to information that has already been released in response to this
Authorization. I understand that the revocation will not apply to my insurance company when the law provides my insurer with the right
to contest a claim under my policy.
Unless otherwise revoked, this Authorization will expire on the following date, event, or condition or in one year:____________
*Please note, all copies for patient records for personal use carry a $1 per page fee. The State of New Jersey allows 30 days to
comply with a record request and walk-ins will be handled accordingly unless there is an emergency. If you are picking up the
records personally, you will be required to show a legal form of identification.
Please indicate type of record(s) requested and approximate date(s) of service (please check box(s) below):
Date(s) in hospital from – to:
Date(s) in hospital from – to:
 Inpatient
 Outpatient
Date(s) in ER:
Date(s) in Clinic from – to:
 Emergency Room
 Clinic
Date(s) of Test:
Type of Test(s):  X-ray  Labs  Pathology  Vascular
 Test results only
 EKG  Echocardiogram € Other: ____________________
Today’s Date: ______________________
Patient’s Signature: _____________________________________________
Parent/Legal Guardian or Authorized Representative: ___________________________________________________
Witness to Signature(s): ________________________________________________
* Name of person, other than requestor, picking up copy of medical record: _________________________________________
*Patients over 18 years of age must request their own records.
If it is determined by the hospital that your records are protected by Federal or State law and regulations concerning confidentiality of
alcohol and drug abuse patient records, the diagnosis and treatment of AIDS, HIV infection or HIV related illness; the following note
will be attached to the information sent to the recipient. If you fail to specify an expiration date, event or condition, this
authorization will expire in 1 year.
NOTE to Recipient of Information: This information has been disclosed to you from records protected by Federal or State confidentiality rules (42
CFR § 2.1 et seq; N.J.S.A. 26:5c-1 et. Seq.) Federal or State rules prohibit you from making any further disclosure of this information unless further
disclosure is expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42 CFR § 2.1 et seq. or N.J.S.A.
25:5c-1, et seq. A general authorization for the release of medical or other information is not sufficient for this purpose. The Federal or State rules
restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse patient.
5/96, 8/01, 2/03, 5/03, 9/07, 9/08, 9/11
Authorization_Release_of_Pt_Rec_&_Info_MR_20_MRec_Rev_9_11.doc
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