Fillable Consent For Release Of Medical Information printable pdf download

CONSENT FOR RELEASE OF MEDICAL INFORMATION

With this form, you authorize the release of your medical health information. Print neatly

and complete all fields. Questions may be emailed to:

health@andrew.cmu.edu

IDENTIFY YOURSELF (you are the client)

Client’s Last Name

First Name

Date of Birth

(mm/dd/yyyy)

Address

9-digit Carnegie Mellon Student Account #

Email address

Phone #

(This is your SS#, or a 9-digit number starting with 999 or 700.)

Please indicate the semester and year when you last attended. (ex: Spring, 2007)

______________________

IDENTIFY THE FACILITIES SENDING AND RECEIVING YOUR MEDICAL INFORMATION

Name of facility or person:

Carnegie Mellon University Health Services

is sending

1060 Morewood Ave, Pittsburgh, PA 15213

information to

Phone: (412) 268 2157 Fax: (412) 268 6357

Address:

You may specify a particular staff member here

if you wish:

is receiving

_____________________________

information from

Phone:

Fax:

SPECIFY THE INFORMATION TO BE RELEASED

Reason for the release of info?

Consent expires on: _______________

_________________________________________________

(mm/dd/yyyy)

For what dates of service do you want info released?

_____________________________

This consent must have a time limit; that does

not exceed one year from Client’s signature date

What categories of information do you wish to have included? Only those items

below. If left blank, consent expires 90 days after

checked will be included.

Client’s signature date.

Immunization records and health history only

Client may terminate this consent at any time by

All medical records except sensitive documents (substance or alcohol

sending a written request to the facility/person

abuse, domestic violence, sexual assault, HIV related, mental health)

identified above to release records. Receipt of a

Include drug and alcohol information.

termination request will cancel future actions, but

cannot reverse the release of information already

Include HIV or aids information.

completed.

Include domestic violence or sexual assault information.

Include mental health information.

Include medical records from other facilities.

Other (please specify):

__________________________________________

CERTIFY THIS REQUEST

I grant my permission for the release of information I’ve specified above. I understand that information being disclosed to a party

outside of UHS may be re-disclosed by that party. UHS and its employees have no responsibility or liability as a result of re-

disclosures.

_________________________________________________________________

_____________________________

Client’s signature (if not 18, an Authorized Representative must sign below)

Date Client signed (mm/dd/yyyy)

____________________________

_________________________________

______________________________

Authorized Representative’s signature

Authorized Representative’s relationship

Date Auth. Rep. signed (mm/dd/yyyy)

to act on behalf of client

_________________________________________________________________

___________________________

Signature of a Facility Staff Member witnessing this signature of Client

Date Witness signed (mm/dd/yyyy)

Witness must verify client’s identity via photo id. If form is received by FAX, verification is to be done by phone, via SS#, visit history, etc.).

RETURN THIS FORM TO: Carnegie Mellon University Health Services, 1060 Morewood Ave, Pittsburgh, PA 15213 FAX:412 268 6357

Signature of Facility staff member who completed the release, and the date completed: __________________________________________________

Consent For Release Of Medical Information

Related Articles

Related forms

Related Categories