Authorization To Release Medical Information printable pdf download

North Hawaii Community Hospital

North Hawaii Medical Group/Native Hawaiian Health Clinic

67-1125 Mamalahoa Highway

67-1123 Mamalahoa Highway, Suite 116

Kamuela, HI 96743

Phone (808) 881-4650, Fax (808) 881-4654

Phone (808) 885-9606, Fax (808) 885-9506

Authorization to Release Medical Information

PLEASE FILL IN ALL BLANKS

(COMPLETE FORM PRIOR TO SUBMITTING TO THE HIM DEPARTMENT)

Patient Name: __________________________________________

Phone: _____________________________

Address: _______________________________________________

Date of Birth: _________________________

City/State/Zip:__________________________________________

Please SEND my medical information to below

Include Name/Title of Provider/Facility/Organization:

_________________________________________

______________________________________________

Street Address: ____________________________

Street Address: ________________________________

City/State/Zip:_____________________________

City/State/Zip:_________________________________

Phone:_______________ Fax:________________

Phone:________________ Fax:___________________

Purpose of Use/Disclosure: ________________________________________________________________________

List specific dates of records to be released:

_______________________________________________________

Date: (this authorization shall be good for one year) __________________________________________________

DATES OF SERVICE TO BE DISCLOSED: _____________________________________________________

I AUTHORIZE THE RELEASE OF THE FOLLOWING RECORDS:

(Check all that apply)

♦North Hawaii Community Hospital [ ] ♦North Hawaii Medical Group [ ] ♦Native Hawaiian Health Clinic [ ]

Any & All Records { } Emergency Room Record { } History & Physical Report { }

Discharge Summary Report { } Consultation Reports{ }

Radiology Report/Film { }

Pathology Report { } Other { }

Office Notes { }

Laboratory Reports { }

The following (marked*) must be initialed by the requestor to be included in the use and/or disclosure of other health

information

__ *Sexually transmitted disease/HIV/AIDS related information and/or records __*Mental Health Information

__ *Genetic Testing information

__**Drug/alcohol, diagnostics, treatment, or referral information

** Federal regulation (in 42 CFR Part 2) requires a description of how much and what kind of information will be disclosed

Restrictions: I understand that the information released may be subject to re-disclosure by the recipient and may no longer

be protected.

Rights: I understand that I may refuse to sign this authorization and that my refusal to sign may not affect my ability to

obtain treatment (see page 2 of this form for certain exceptions). I may inspect or obtain a copy of any information to be

used and/or disclosed under this authorization in accordance with organizational policy. I understand that I have the right to

revoke this authorization in writing (see page 2 of this form). My revocation will be effective upon receipt, but will not be

effective to the extent that this organization has taken action in reliance upon this authorization.

Retain original copy in Patient Record

Revised 6-2012

Authorization To Release Medical Information

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