Authorization To Release Health Information

Appointment Date: __________________________________

Seaport Community Health Center

Medical Records

Patient Name: ___________________________________________

P.O. Box 439

Patient Address: _________________________________________

Bangor, ME 04402-0439

(207) 404-8101 Fax (207) 990-1248

Date of Birth: ____________________________________________

For Appointments: (207) 338-6900

Patient Phone: ___________________________________________

Authorization to Release Health Information

I give my permission for PCHC (Penobscot Community Health Care) and its employees to:

Obtain My Medical Information indicated below FROM

OR

Release My Medical Information indicated below TO

Name of Person or Organization: ___________________________________________________________________________________________________

City/State/Zip: __________________________________________________________________________________________________________________

Phone: ________________________________________________________ Fax: ___________________________________________________________

To be

Mailed

Faxed

Emailed (if requesting secure electronic delivery) ____________________________________________________________

Email Address

Dates of Care or Dates of Records

All Records ___________________________________

OR I wish to release Only those items selected below:

Clinic Records __________________________

Immunization Records ___________________________

Lab Reports ____________________________

Hospital Records _______________________________

Radiology Reports _______________________

Summary Records ______________________________

Other Records __________________________

Sensitive Medical Information (Substance Abuse, Mental Health, HIV/AIDS): THIS SECTION MUST BE COMPLETED

I specifically authorize the disclosure of the health care information relating to the testing, diagnosis and treatment for:

Dates of Care or Dates of Records

HIV/AIDS ____________________________________________

Mental Health _________________________________________

Alcohol/Drug Abuse __________________________________ (I understand this information cannot be redisclosed without my specific consent)

I wish to review the Sensitive Medical Information selected above (Substance Abuse, Mental Health, and/or HIV/AIDS records) prior to release.

OR

I DO NOT Authorize the Release of Substance Abuse, Mental Health, and/or HIV/AIDS records.

The purpose of the disclosure is (check where applicable):

Coordination of Medical Care

Transfer of Medical Care

Insurance

Legal

Disability

School Entry

For Personal Use, please explain _____________________________________

Other, specify ________________________________________

Other Instructions: _____________________________________________________________________________________________________________

Please use this space to indicate any special requests, information you do not wish disclosed, a different event or expiration for this Authorization, or any other instructions which may assist us with your request.

This Authorization is for

a one-time disclosure OR

multiple disclosures (Note: authorization for disclosure of mental health records cannot be

continuing authorizations)

This Authorization expires: ________________________ Note: If left blank, this form will expire in ninety (90) days for one-time disclosures or in (1) year for

multiple disclosures of health records. Exception: Six (6) months for children in residential and foster care.

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