Authorization To Release Information Form Page 2

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i autHoRiZe tHe puBliC disClosuRe oF my peRsonal HealtH inFoRmation as desCRiBed BeloW:
K name and age
K city of residence
K hospital admission, discharge or treated/released status
K brief extent of injuries or illness
K diagnosis, treatment, prognosis
K photographs, videotape or audiotape
K other (describe) _____________________________________________________________________________________________________________
FoR tHe puRpose oF:
K hospital produced publications/promotions/advertising
K hospital events/presentations/projects
K hospital web-site
K educational purposes/professional conferences
K all news media
K other use (describe) _________________________________________________________________________________________________________
authorization and expiration:
i understand that if the person or entity that receives the above information is not a health care provider or health plan covered by federal privacy
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regulations, the information described above may be redisclosed by such person or entity and will likely no longer be protected by the federal privacy
regulations.
i understand that treatment or payment of my claim will not be impacted by not signing this form. research related treatment is strictly voluntary.
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i understand that by signing this authorization it gives the researcher(s) the permission to use or disclosure my personal health information for such
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research.
i understand that my records/protected health information cannot be released unless i sign this form.
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as described in the notice of privacy practices of ohiohealth i understand that i may revoke this authorization in writing at any time, except to the extent
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that action has been taken by ohiohealth in reliance on this authorization, by sending a written revocation to: (entity's) medical record department,
(entity's address.) attn: information associate.
riverside health center
riverside methodist hospital
grant medical center
grady memorial hospital
doctors hospital
doctors hospital nelsonville
(614) 566-5000
(614) 566-5000
(614) 566-9000
(740) 615-1030
(614) 544-1000
(740) 753-1931
mcconnell health center
dublin methodist hospital
ohiohealth home care
marion general hospital
hardin memorial hospital
neighborhood care
(614) 566-5356
(614) 544-8000
(614) 566-0888
(740) 383-8400
(419) 673-0761
health center
marion area Physicians
oPg oh Physicians group
o’bleness hospital
medcentral hospital
shelby hospital
(740) 383-8010
(614) 544-8376
(740) 592-9387
(419) 526-8525
(419) 342-1715
i understand that this authorization may include information concerning testing, diagnosis or treatment of HiV (Human immunodeficiency
Virus),aids (acquired immunodeficiency syndrome), psyCHiatRiC and/or dRuG/alCoHol tReatment and/or assault ReCoRds that may
be in my medical record.
this authorization for release of protected health information for the date of service indicated is effective until ___________ or for a maximum of one year
from the date signed below.
i hereby authorize _________________ (name of entity) to disclose to the party (parties) named in this document, information from my medical record for
the reasons and time specified.
X
signature of Patient ______________________________________________________________________ date ___________
time ___________
signature of individual authorized by Patient __________________________________________________ date ___________
time ___________
relationship to Patient ____________________________________________________________________
prohibition on Redisclosure: i understand this information has been disclosed from records whose confidentiality is protected by Federal law. Federal
regulations (42 cFr part 2) prohibit you from making any further disclosure of this information except with the specific written consent of the person to
whom it pertains. a general authorization for the release of medical or other information, if held by another party, is not sufficient for this purpose. Federal
regulations state that any person who violates any provision of this law shall be subject to prosecution under Federal law.
according to ohio Revised Codes there is a per page fee for records. the fee will be dependent upon the number of copies requested and other
reasons as specified in oRC 3701.741 at codes.ohio.gov/oRC.
Patient identiFication label
*ROI*
autHoRiZation to
Release inFoRmation
1015200 (3/19/2015) Page 2 of 2

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