Authorization For Release Of Protected Health Information
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2GBMC – Health Information Management - Correspondence
6701 North Charles Street Baltimore, MD 21204
Phone: 443-849-2274
Fax: 443-849-3223
Email:
Authorization for Release of Protected Health Information
Patient Information:
Patient Name
Birth Date
Address (include street, city, state and zip code)
Telephone No.
(
)
Email Address
(must be provided if electronic copies are requested)
Release of Information:
I hereby authorize:
Greater Baltimore Medical Center
Other facility name:
___________________________________
to release health information from the medical records of the above-named patient.
For the following purpose:
At my request
Insurance
Continuance of Medical Care
Legal
Other: ___________________________________________________
To:______________________________________________________________________________________ _
__________________________________________________________________________________________
Name/Address of person/organization to which disclosure is to be made
For treatment dates: ___________________________
Inpatient
Emergency Room
Outpatient Surgery
Clinic
Type of Access
Continuing Care Information (Discharge Summary, History and Physical,
Authorized:
Consultation, Operative Report, Diagnostic and Medical Tests, Pathology
Paper copies
Report
Electronic copies
ER Record
(e-mail address must be provided)
Clinic Record
Inspection of the
Other_________________________________________________________
record
THIS IS A TWO SIDED FORM. THE PATIENT OR REPRESENTATIVE MUST SIGN ON THE BACK.
722-174 (11/14)
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Parent category: Legal