Authorization To Release Protected Health Information
Download a blank fillable Authorization To Release Protected Health Information in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Authorization To Release Protected Health Information with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2*151-036*
*Hospital & Clinic staff:
Affix patient label here. If providing
records to the patient, update the
AUTHORIZATION TO RELEASE PROTECTED
Staff Use section of the form and
HEALTH INFORMATION
update Quick Disclosure.
Patient Identification
Patient Name
Nickname/Maiden/Other
Patient
Information:
Address/City/State/Zip
Date of Birth
Last 4 of SSN#
Phone
_____ / _____ / ________
Record
UC San Diego Health
Other: _______________________________________________________
Holder:
Address/City/State/Zip
Who has the
information you
Phone
Fax (Urgent Patient Care only)
want released?
Name of Hospital/Clinic/Persion
Release
Records to:
Street Address/City/State/Zip
Where do you want
records sent?
Who do you want to
Phone
Fax (Urgent Patient Care only)
receive records?
Purpose:
Continued Care – Appointment Date (if known): _____ / _____ / ________
Legal
Personal
Insurance
Disability
Other (please specify):
Health
Routine Record Sets – For dates of service: _____________________________________
Information to
Hospital Stay (History and physical, operative report, discharge summary, progress notes, lab, radiology reports)
be Released:
Clinic visit (office notes, procedure notes, operative notes, lab, diagnostic and radiology results)
What do you want
Other Records – Please Specify Type: ______________________________________________________
sent or released?
Billing Records
Radiology Images (only) Mail
Pick-up
Email** (See bottom of page 2 for email limitation)
Sensitive
Sensitive information WILL BE RELEASED unless you tell us not to by initialing below:
Information:
______ Do Not Release Drug & Alcohol abuse treatment records
______ Do Not Release Mental Health/Psychiatric treatment records
______ Do Not Release HIV Test Results
______ Do Not Release Genetic Test Results
Authorization I understand this authorization is voluntary. Treatment, payment enrollment or eligibility for benefits may not
be conditioned on signing this authorization except if the authorization is for: 1) conducting research-related
treatment, 2) to obtain information in connection with eligibility or enrollment in a health plan, 3) to determine an
entity’s obligation to pay a claim, or 4) to create health information to provide to a third party.
I understand this authorization may be revoked in writing at any time except to the extent that action had been taken
in reliance on this authorization. Unless otherwise revoked this authorization will expire 12 months after the date of
signing this form.
_______________________________________________ __________________________________ ______________ ___________ AM/PM
Signature of Patient or Authorized Representative
Print Name
Date
Time
________________________________ ________________________________ _________________ ______________ ___________ AM/PM
Relationship (If signed by other than Patient) If Interpreted: Signature OR ID of Interpreter
Language
Date
Time
Telephone
Video
*Staff Use
Info Released By:
On Date:
151-036 (3-17) Page 1 of 2
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal