Authorization For Release Of Identifying Health Information printable pdf download

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AUTHORIZATION FOR RELEASE OF IDENTIFYING HEALTH INFORMATION

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Health information may be disclosed by (name/title/organization releasing information, address):

Health information may be disclosed to (name/title/organization receiving information, address):

Patient Name

Patient ID Number

Patient Address

Patient Phone Number

Date of Birth

Previous Name

I authorize the professional office named above to release health information identifying me (which may include information about

HIV infection or AIDS, information about substance abuse treatment, and information about mental health services) under the

following terms and conditions:

1. Detailed description of the information to be released (check all that apply):

All health care information in my medical record

Health care information in my medical record relating to the following treatment or condition:

Health care information in my medical record for the date(s):

Other:

2. Reason(s) for this authorization (check all that apply):

At Patient’s Request.

At doctor’s Request. Other:

3. Expiration date of this Authorization:

90 days from the date signed (Authorization will expire in 90 days if not otherwise specified.)

On (date: mm/dd/yyyy):

When the following event occurs:

I understand that I do not have to sign this authorization form in order to receive health care benefit (treatment, payment, enrollment,

or eligibility for benefits). However, I do have to sign this authorization form to receive health care when the sole purpose of the

health care is to create information for a third party, or to take part in a research study.

I can revoke this authorization later. I understand that: 1) I must revoke my authorization in writing; 2) If I revoke my authorization, it

will not affect any actions already taken based upon this authorization; and 3) I may not be able to revoke this authorization if the

purpose of it was to obtain insurance.

Once disclosed, health care information may be subject to redisclosure by the recipient in which privacy laws may no longer protect

the information. I understand that this authorization does not permit the release of information related to health care provided to me

more than ninety days after the date of this authorization. This prohibition does not extend to insurance companies.

I HAVE READ AND UNDERSTAND THIS FORM. I AM SIGNING IT VOLUNTARILY. I AUTHORIZE THE DISCLOSURE OF MY

HEALTH INFORMATION AS DESCRIBED IN THIS FORM.

Dated ______________________ Patient signature _______________________________________________

If you are signing as a personal representative of the patient, describe your relationship to the patient and the source of your authority

to sign this form:

Relationship to Patient ______________________ Print Name

Source of Authority

KEC recordreleaseform0315

Authorization For Release Of Identifying Health Information