Authorization: Release Of Information Form
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1AN:
AUTHORIZATION: RELEASE OF INFORMATION FORM
SD:
MN:
PN:
BD:
AP:
Patient Name: _______________________________________________
Date of Birth: ___________________________
Telephone Number: __________________________________________
Social Security #: _________________________
Address: _________________________________________________________________________________________________
1.
I authorize the use or disclosure of the above named individual’s health information as described below:
2.
I authorize – Name: _________________________________________________________________________________
Address: _________________________________________________________________________________
To:
Release records to
Obtain records from
Exchange information with
Name: _____________________________________________________________________________________
Address: ___________________________________________________________________________________
3.
The type of information to be used or disclosed is as follows (check the appropriate boxes and include other information
such as dates where indicated)
and has been generated prior to the signing of this authorization.
Emergency room report (date) ___________________________________
Operative report (date) ________________________________________
Pathology report (date) _________________________________________
History & physical report (date) __________________________________
Most recent discharge summary
(dates) from _______________________ to __________________________
Lab results
(dates) from _______________________ to __________________________
X-ray and imaging reports
(dates) from _______________________ to __________________________
Consultation reports
(dates) from _______________________ to __________________________
Entire record
(dates) from _______________________ to __________________________
Other (please describe) _____________________________________________________________________________
4.
I authorize the entity or person listed in #2 above to release information from my record that may include the following:
YES
NO
Behavioral or mental health services
Treatment of alcohol and / or substance (drug) abuse
Testing for HIV, HIV test results, diagnosis of HIV positive, AIDS, ARC or other AIDS related disease.
5.
The purpose of the release of these records is
Personal use
Continuation of medical care
Pending legal action
Insurance company or other third party reimbursement
Other (please describe) ______________________________________________________________________________
6.
I understand that I have a right to revoke this authorization at any time. I understand if I revoke this authorization I must do
so in writing and present my written revocation to the Medical Record Department. I understand that the revocation will
not apply to information that has already been released in response to this authorization. I understand that the revocation
will not apply to my insurance company when the law provides my insurer with the right to contest a claim under my policy.
7.
Unless I specify differently, this authorization will expire (date or event) ______________________ or if I fail to specify, this
authorization will expire one year from the date of the signature.
8.
I understand that once the above information is disclosed, it may be re-disclosed by the recipient and federal privacy laws
or regulations may not protect the information.
9.
I understand authorizing the use or disclosure of the information identified above is voluntary. I need not sign this form to
ensure healthcare treatment.
Note: With the exception of records being copied for continuity of care or insurance company or other third party
reimbursement, there WILL be a charge for copies of records.
______________________________________/________
_______________________________________/________
Signature of patient or patient’s representative
Date
Signature of witness
Date
If signed by patient’s representative, relationship to patient: _____________________________________________________________________________
If patient representative, provide documentation or explanation of your authority to act for the patient. (Attach copy.)
-
Administrative Use Only –
Driver’s license number: _________________________________________________________________________________
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