Authorization For Release Of Information Form (Page 2 of 2) in pdf

MERIDIAN HEALTH

AUTHORIZATION FOR RELEASE OF INFORMATION

CMR-003 (5-11)S

PAGE 2 OF 2

*RI0000*

AUTHORIZATION FOR RELEASE OF INFORMATION

ALL REQUESTS WILL BE PROCESSED IN ACCORDANCE WITH APPLICABLE FEDERAL AND STATE LAWS

Copies will be provided within thirty days of a proper written request.

FEE SCHEDULE:

$1.00 per page for first 100 pages

$0.25 a page for remaining pages but not to exceed $200.00 per admission

Plus postage

FEE SCHEDULE ABOVE IS NOT APPLICABLE FOR THE FOLLOWING:

1. Records mailed directly to a Physician/Health Care Facility

The facility will mail copies of requested records directly to a Physician/Health Care Facility at no charge to the patient.

2. Defendant’s attorney and Third Party Requestors not representing the patient.

For information on the applicable fee schedule contact the Health Information Department -Release of Information.

3. Records in other than paper media.

Please see/contact the Health Information Department or Radiology Department as appropriate.

___________ By initialing I acknowledge that I have read the above Fee Schedule.

Receipt of specimen (if applicable)

NOTE: Certain substances relating to this specimen may be considered carcinogenic,

biohazardous, toxic or irritant material. Biohazardous is identified as material that may contain

blood-borne pathogens that are potentially infectious.

I have read this warning label on the specimen and I am aware of the risk in exposure to these

substances.

Signature of Person Receiving Sample__________________________________________Date: _________ Time:_____am/pm

For MH Department Use Only:

If the patient is a minor, a parent, next of kin or legal guardian must sign the authorization, with the

following exceptions and as prohibited by law:

• The minor is pregnant. • The minor is married. • The minor is emancipated (court determined)

• The treatment is a state funded mental health service. • The treatment is for Drug and/or Alcohol Abuse.

• The treatment is for a Sexually Transmitted Disease. • The treatment is for AIDS or HIV.

If patient is deceased, proof of executor or administrator of estate is required, if not applicable

surrogate certificate.

IDENTIFICATION VERIFIED VIA:

■ ■

DRIVER’S LICENSE

GOVERNMENT ISSUED ID Verified By:____________________________

IF COPIES ARE HANDCARRIED, OBTAIN SIGNATURE BELOW:

Signature: ___________________________________________ Date: __________ Time:______am/pm

Authorization For Release Of Information Form Page 2