Authorizations For Use Or Disclosure Of Medical Record Information

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Authorizations For Use or Disclosure of Medical Record Information
Medical Record #
6011 E. WOODMEN ROAD STE 305, COLORADO SPRINGS. CO 80923
PHONE: 719-884-9962
FAX: 719-884-9963
Patient Information:
Patient Full Name: ______________________________________________________________ Date of Birth: __________________
Patient Address: ________________________________________________________________ Home Phone: __________________
City: _________________________________ State: _________ Zip: __________________ Work Phone: __________________
I hereby authorize Exceptional Care for Women to release my medical records to the following:
I hereby authorize the following to release my medical records to Exceptional Care for Women:
Name/Facility: _______________________________________________________
Attention: ________________________________
Address: ____________________________________________________________
Phone: ___________________________________
City: _________________________________ State: _________ Zip: __________________ Fax: _____________________________
Purpose of Request:
* Personal
Continuing Care
* Legal
* Insurance
* Other____________________________
* COPY FEE: We reserve the right to charge a reasonable fee for the cost of producing and mailing the copies. Base fee of $15 per chart. Please
make checks payable to Exceptional Care for Women. Charts will be copied once payment is received.
Information to be released:
PLEASE BE SPECIFIC – Include dates of treatment & provider name if applicable.
_______________________________________________________________________ Date (s) of Treatment _______________________
_______________________________________________________________________ Date (s) of Treatment _______________________
Authorization for Release of Statutorily Protected Information:
DO NOT leave this section blank –
The requested medical record MAY or MAY NOT contain information that is statutorily protected. You must check
either “Yes” or “No” and initial each category for Exceptional Care for Women to properly process your medical record request.
Release Record? Check one
YES
or
NO
Mental Health
Initial Here: ________________
HIV Tests & Related Information
Initial Here: ________________
Alcohol and/or Substance Abuse
Initial Here: ________________
Genetic or Hereditary cancer testing
Initial Here: ________________
Please confirm that you have checked “Yes” or “No” and initialed all 3 protected information categories above even if they do not
necessarily apply to the patient’s records. If information is not released and/or form is incomplete, ECW may be unable to fulfill
this request.
Sensitive Information:
Please check or indicate below any sensitive information that you DO NOT want released.
Abortion
Sexually Transmitted Disease
AIDS/ARC
Genetic
Domestic Sexual Assault
Other (s) _______________________________________
______________________________________________________________________________________________
Patient’s Signature
Date*
Know Your Privacy Right
______________________________________________________________________________________________
Refer to the HIPAA
Parent/Legally Recognized Representative Signature/Relationship to Patient**
Date*
“PRIVACY POLICY”
______________________________________________________________________________________________
Witness
Date
*This Authorization is valid for 90 days (30 days for alcohol/drug abuse treatment) unless you specify otherwise: __________. You may revoke this
Authorization at any time by providing a written statement to ECW where the Authorization was originally submitted, except to the extent that ECW has
already completed action on it.

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