Authorization Form For Release Of Protected Health Information
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1
2AUTHORIZATION FOR RELEASE OF
PROTECTED HEALTH INFORMATION
Patient Name: ____________________________________________________ Date of Birth: _______________________________
Maiden/Other Name: ______________________________________________ MRN (if known):_____________________________
Address: _________________________________________________________ Phone Number: _____________________________
City: ____________________________________________________________ State: __________ Zip Code: _________________
2
1
. RECEIVIN G PARTY & D ELIVERY METHOD - CHOOSE ON E:
. PURPOSE OF RELEASE/D ISCLOSURE- CHOOSE ON E:
Mail the records/information to me (see fee below).
My personal records
Attorney
Deliver the records to my email electronically (see fee below).
Medical Care/Second Opinion
Disability
Email: _______________________________________________
Other: _________________________________________
Release the records to (physician name if for medical care):________________________________________________________
Address: ____________________________________________________________________________________________________
City: ____________________________________________________
State: _____________ Zip Code: _____________________
Phone: __________________________________________________
Fax Number: ______________________________________
3.
D ESCRIPTION OF HEALTH IN FORMATION /RECORD S TO BE D ISCLOSED - CHOOSE ON E:
Send complete medical record without X-ray/Films (CD).
Send complete medical record with X-ray/Films (CD)
Send partial medical records:
Specify dates of service: From: ______________________ To: ______________________
Send specific section circled below: Specify dates of service: From: ______________________ To: ______________________
History and Physical
X-rays/Films (CD)
Consultations
MRI Report
Discharge Summary
Rehabilitation
Office Notes
Lab Results
Operative Reports
Other: ____________________________________________
You must check this box if you are also requesting Billing Records
4.
EXPIRATION , REVOKE OF AUTHORIZATION , & RE-D ISCLOSURE
I understand this authorization may be revoked in writing at any time, except to the extent that action has been taken in reliance on
this authorization. Unless otherwise revoked, this authorization has no expiration date. When my health information is released
pursuant to a valid authorization, the information released may be subject to re-disclosure by the recipient and may no longer be
protected by Federal Privacy regulations.
5.
FEE FOR RECORD S
Federal and state laws allow a fee to be charged for copying patient records and I will be responsible for the payment of such fees,
unless the records are sent directly to a physician or healthcare facility. Patient copy fees: X-ray or MRI CD’s are $5 each. Print fee
or electronic email delivery for records are: $0.36 per page for pages 1-200, and $0.12 per page for pages 201+. $400 maximum fee.
6.
RELEASE AN D WAIVER
I understand that my medical record may also include information on diagnosis/treatment related to psychiatric or psychological
conditions, chemical dependency/alcohol abuse, communicable or infectious diseases (ie. AIDS, HIV, ARC, TB, and hepatitis). I
hereby waive any privilege concerning such information for the purpose(s) of releasing it to the party or parties authorized above. I
also release Resurgens, each of the Resurgens offices and their officers, trustees, agents, and employees from any and all liabilities,
damages, and claims which might arise from the release of the health information authorized by me above. In cases where someone
other than the patient executes the authorization, I understand documentation may be required to support the disclosure of
personal health information as required by state and federal law. In most cases, records are processed within 7 days. Please be
aware that federal and state law allows healthcare providers 30 days to respond to written requests for records.
__________________________________________________
________________________________________
Signature of Patient/Legal Representative
Date
__________________________________________________
_________________________________________
Printed Name
Relationship to Patient
Fax requests to: 678-459-3166 or mail requests to: Resurgens Centralized Medical Records
270 Chastain Rd, Kennesaw GA 30144 Phone: 678-594-6100
A COPY OF THIS COMPLETED, SIGNED AND DATED FORM MUST BE PLACED IN THE PATIENT’S MEDICAL RECORD
Rev. 05/05/2016
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