Records Release Form For Disclosure Of Protected Health Information

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LAFENE HEALTH CENTER
Telephone: (785) 532-6544
Kansas State University, 1105 Sunset Avenue, Manhattan KS 66502
FAX: (785) 532-3425
RECORDS RELEASE FORM
FOR DISCLOSURE OF PROTECTED HEALTH INFORMATION
Instructions: All sections 1- 7 must be completed. Please print
all information except for signatures.
Section 1: PATIENT IDENTIFICATION.
Print Name:____________________________________________________________Alias/Maiden:__________________________________
Street Address, City, State & Zip Code____________________________________________________________________________________
Student I.D. Number:________________________________________ Date of Birth_______________________________________________
Section 2: TYPES OF RECORDS/INFORMATION TO BE DISCLOSED. Initial all appropriate boxes.
1. All records contained in my medical chart to include all records from outside providers. (This will include everything transferred
to us.) Excluding the three types of records listed in number 4 of this section.
2. Partial medical records. Please specify specifically which records you want disclosed. __________________________________
__________________________________________________________________________________________________________
3. Communication between parent and healthcare provider for ____ all visits (or) ____________________dates only.
4. To disclose the following protected information, authorization is designated by initialing the appropriate box.
Alcohol or substance abuse or treatment
Psychiatric/mental health diagnosis or treatment by a
mental health provider excluding psychotherapy notes
HIV antibody test results / AIDS Diagnosis
Section 3: PURPOSE for which you want records disclosed. __________________________________________________________________
___________________________________________________________________________________________________________________
Section 4: Facility/Person authorized to SEND information.
Section 5: Facility/Person authorized to RECEIVE information.
_____________________________________________________
_______________________________________________________
_____________________________________________________
_______________________________________________________
_____________________________________________________
_______________________________________________________
_____________________________________________________
_______________________________________________________
PH:______________________FAX:_______________________
PH:______________________FAX:_________________________
STUDENT RECORDS (FERPA)
NON-STUDENT RECORDS (HIPAA)
Section 6a: EXPIRATION OF AUTHORIZATION
Section 6b: EXPIRATION OF AUTHORIZATION This authorization will
This AUTHORIZATION does not expire unless an
expire on ________________________(date).
Not to exceed one year or if left blank,
this AUTHORIZATION will expire 90 days from date of signature.
expiration date is listed below:
•
I understand this information may be transmitted by fax if necessary for urgent medical care.
______________________________________ (date)
•
I understand that if the person or entity that receives the described records/information is not
a healthcare provider or health plan covered by federal privacy regulations, the
•
I understand this information may be transmitted by fax if
records/information may be redisclosed and may no longer be protected by those regulations.
necessary for urgent medical care.
•
I understand that federal or state law may protect certain records and I am requesting that any
•
I understand that if the person or entity that receives the
and all such protected records be disclosed under this authorization if initialed in Section 2,
described records/information is not an educational institution,
#
4.
the records/information may NOT be redisclosed and may no
•
I understand that I may revoke this authorization at any time by delivering a written
longer be protected by those regulations.
revocation to: Health Information Management Department, Lafene Health Center, 1105
•
I understand that federal or state law may protect certain
Sunset Ave., Manhattan, KS 66502
records and I am requesting that any and all such protected
•
If I revoke this authorization it will have no effect on actions already taken on reliance on this
records be disclosed under this authorization if initialed in
form.
#
Section 2,
4.
•
The covered entity will not condition treatment, payment, enrollment or eligibility for
•
I consent to the release of the above records.
benefits on whether the individual signs the authorization.
The Family Educational Rights and Privacy Act (FERPA), 20 U.S.C. 1232g,
•
I authorize the disclosure of the records/information described. I have read and understand
prohibits access to the enclosed records by anyone other than the recipient
this form. I am the patient listed or am authorized to act on behalf of the patient as the
unless specific written permission for further dissemination is received from any
and all students or former students of this institution who are personally
patient’s personal representative. I also permit disclosure of the records upon presentation of
identifiable from information contained in the records.
a photocopy of this authorization.
_______________________________________________________________________________
_____________________________
(Signature of patient) or if under 18 years of age (Parent, Legal Guardian, Legal Representative)
(Date)
If you are not the person listed in Section 1, you must describe your relationship to the person in Section 1. __________________________________________________________
________________________________________________________________________________
_____________________________
(Witness signature)
(Date)
_____________
FOR OFFICIAL USE: DISCLOSED BY:____________________________________
Date:____________
12/14/09 RECORDS RELEASE Form

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