Authorization For Release Of Health Information Form printable pdf download

Patient Information: I give permission to release the health information of:

(One Patient Per Form)

Patient Name: ____________________________________________

Date of Birth: ________________________________________

Street Address: ___________________________________________

Last 4 numbers of SSN:__________________________

City, State, Zip: ___________________________________________

Telephone: (

) ____________________________________

Email address: _______________________________________________________________________________________________________________

Release Information From:

Release Information To:

Carolinas Healthcare System

Charlotte-Mecklenburg Schools

____________________________________________________________

(List applicable Facility(s) and/or Practice(s)

(Name of facility, person, company)

(Relationship)

____________________________________________________________

PO Box 30035 Charlotte, NC 28230-0035

____________________________________________________________

(Street Address or PO Box, City, State, Zip Code)

____________________________________________________________

(Phone number)

(Fax number)

980-343-6980

__________________________________________________________

(Phone number)

(Fax number)

PURPOSE OF RELEASE (check reason):

Request of individual/personal

Continued patient care

Insurance

Legal purpose including discussions & proceedings

X Other__Sports Medicine including oral & written communication__________________________

Fill in dates of treatment for records to be released:

Treatment dates: From ___Aug 1, 2016_____________To __July 31, 2017 _______________________

Hospital Summary: May include history & physical, discharge summary, operative notes, consults, diagnostic test results, medication list,

allergies.

Office/Clinic Summary: May include most recent office visits, physical exam, consults, diagnostic test results.

Hospital (check all that may apply):

Office/Clinic (check all that may

Behavioral Health/Sub. Abuse (check all that may

Hospital Summary

apply):

Discharge Summary

Emergency Record

Office/Clinic Summary

Hospital Summary

History and Physical

Cardiac Reports/EKG

Office Visits

Assessments

Consultation reports

Other_____________

X Physical Exam

Discharge Summary

Operative Reports

__________________

X Laboratory Reports

Physician Orders

Laboratory reports

__________________

X Radiology Reports

Progress notes

Radiology/X-Ray Reports

__________________

X Other Research Participation

Medications

Pathology reports

__________________

X ATC Medical Records___

Lab reports

X Nutrition Services

Other ____________________________________

Entire Record (Not including

Entire record (Not including psychotherapy notes)

psychotherapy notes)

Entire Record (Not including psychotherapy notes)

FORMAT:

DELIVERY METHOD:

CD (charges may apply)

Reg.US Mail

Pick-up

Fax, where permitted

Email Address noted above, where permitted

Overnight/Express Mail Service, where permitted

Paper copy (charges may apply)

Secure email

Other___________________________________________________

Other: ____________________________________________________

PATIENT’S RIGHTS – I understand that:

I can cancel this permission at any time. I must cancel in writing and send or deliver cancellation to releasing facility or practice named

above. Any cancellation will apply only to information not yet released by facility or practice.

This is a full release including information related to behavioral/mental health, drug and alcohol abuse treatment (in compliance with 42

CFR Part 2), genetic information, HIV/AIDS, and other sexually transmitted diseases.

Once my health information is released, the recipient may disclose or share my information with others and my information may no

longer be protected by federal and state privacy protections.

Refusing to sign this form will not prevent my ability to get treatment, payment, enrollment in health plan, or eligibility for benefits.

CHS will not share or use my health information without my permission other than by ways listed in CHS’s Notice of Privacy Practices

or as required by law. The Notice of Privacy Practices is available at .

A fee may be charged for providing the protected health information.

I have a right to receive a copy of this form upon request.

This permission expires one year after the date of my signature unless another date or event is written here: _____________________________

Signature: ______________________________________________ Print Name: ______________________________________ Date:______________

Note: If the patient lacks legal capacity or is unable to sign, an authorized personal representative may sign this form.

Note the relationship/authority if signature is not that of the patient (Written Proof May be Requested):

Healthcare Agent/POA

Guardian

Executor/Administrator/Attorney in Fact

Spouse

Parent

Adult Child

Affidavit Next of Kin

Other: ___________________________________

Note: If minor consented for their outpatient treatment for pregnancy, sexually transmitted disease or behavioral/mental health without parental

consent, the minor must sign this authorization. When the patient is a minor being treated for substance abuse, the minor must sign this

authorization, regardless of who consented for treatment.

Signature of Minor:_______________________________________ Print Name: ______________________________________ Date: _____________

Authorization given to patient / Date of release:

via

Mail

Fax

Other___________

__________________

ID Verified

DL/Other ID

CHS Employee Name & Title:

CHS Employee Signature:

_Date:_____________________

Patient Information or Sticker

*905*

Name:

DOB:

Medical Record #:

Carolinas HealthCare System

Account #:

AUTHORIZATION FOR RELEASE

OF HEALTH INFORMATION

Authorization For Release Of Health Information Form

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