Authorization For Disclosure Of Protected Health Information

Authorization for Disclosure of Protected Health Information - HOSPITAL

Print patient’s legal name ___________________________________________Previous Names ________________________________

Address, City, State Zip __________________________________________________________ Birth date _____/______/__________

Phone numbers (Home) ______-_______-___________ (Work) ______-_______-___________(Other) ______-_______-________

This form, when completed and signed, authorizes the parties below

to release and/or exchange protected information from records.

I authorize:

Ridgeview Medical Center

500 South Maple St, Waconia, MN 55387

Fax (952) 442-6538 | Phone: (952) 442-2191 ext 5430 or 5139

☐

To release

RECEIVE FROM the following party:

Person, clinic or organization : __________________________________________________________________________________

Address: ____________________________________________________________ City: __________________________________

State: _____________ Zip code: _________________ Phone: ______-_______-___________ Fax: ______-_______-___________

☐ Any and all records (includes all types of records listed below):

the following information:

☐ History/Consults/ED

☐ Physical Therapy

☐ Itemized Bills

☐ Operative Reports/Pathology

☐ Pathology Slides

☐ Progress Notes

☐ Radiology Films/Images ☐ Discharge Summary ☐ Radiology/Lab Report

☐ Other: ____________________________________________________________________________________________________

For condition or dates of treatment: ____________________________ (If blank, we will release 1 year’s worth of most recent records.)

I would like to receive my records by: ☐ I will pick up ☐ Mail ☐ Email ________________________________________________

I understand the following:

Except for psychotherapy notes (which are not included in my medical record), all records of treatment for mental health, chemical

dependency, sickle cell anemia, genetic conditions and AIDS/HIV will be released. If I don’t want these to be released, I will place a

checkmark here: _______. I DO NOT want the following records released:

☐ Alcohol/Drug Use or Abuse Records ☐ Mental Health Records ☐ AIDS/HIV Records ☐ Sickle Cell ☐ Genetic Conditions

Purpose of Disclosure:

☐ Continued care by another provider ☐ Insurance claim

☐ Personal use

☐ Coordination of Services

☐ Legal

☐ Other ____________________________________

☐

If releasing records to yourself, should the envelope be marked “Personal and Confidential”?

Yes

This form expires one year after I sign it or sooner (specify here: __________________________________________). The time period

noted here may exceed one year in certain situations specified by law.

I understand that I may revoke this authorization at any time by sending written notice to the health facilities noted above. I understand

that any release of information made prior to my revocation in compliance with this authorization shall not constitute a breach of my

rights to privacy. Once the records are released, Ridgeview Medical Center cannot prevent them from being released to a third party. At

that point, the records may no longer be protected by state and federal privacy laws.

I hereby authorize the above facilities to disclose medical information concerning the above named patient. I understand that the

information to be released may include information regarding mental health, alcohol and drug usage, also HIV related information. I

understand that once information is disclosed, it may be subject to redisclosure by the recipient and may no longer be protected. I further

understand that I may refuse to sign this authorization and that my refusal will not affect my ability to obtain treatment or payment or

my eligibility for benefits.

___________________ __________________________________________ ____________________________________________

Signature of client or authorized person

Authorized person’s authority to sign

Date

Reason patient is unable to sign: ☐ Minor ☐ Deceased ☐ Other: ___________________________________

To be valid, this form must be filled out completely and signed. A copy is valid if it has not been altered.

Office Use: ☐ Mailed ☐ Faxed ☐ Patient Pickup ☐ Email | ☐ Identification Verified Initials ______ Date: ___________________

MR#: _____________________________ Visit ID: __________________________

Authorization For Disclosure Of Protected Health Information - Hospital

Related Articles

Related forms

Related Categories