Form 4856-12678 - Authorization To Obtain, Release Or Review Protected Health Information - Winnie Palmer Hospital For Women & Babies
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1*4856-12678*
ORLANDO HEALTH
1414 Kuhl Ave.
LINE UP PATIENT I.D. LABEL HERE
Orlando, FL 32806
AUTHORIZATION TO OBTAIN, RELEASE OR REVIEW PROTECTED HEALTH INFORMATION
Patient Name:________________________________________ Social Security # (last 4 digits): _______________________
Address:______________________________________________________________________________________________
Date of Birth: ____/____/____ Date of Service:______________________
Phone #:______________________________
Identification Shown:___________________________________________ Mail q Secure Email q / Pick Up: Paper q CD q
Email Address
I hereby authorize Orlando Health to use and disclose to: q
or obtain from: q
or allow review: q
Name of Facility or Person
Phone
Street Address
City
State
Zip Code
SEND RECORDS TO: (Name of Facility or Person)
Street Address
City
State
Zip Code
the following information contained in my medical record regarding my hospitalization, care and treatment (please initial):
____ Complete Record
____ All Diagnostic Test Results
____ Pathology Report(s)
____ Abstract of Record
____ Consultation
____ Lab Only
____ Therapy Records
____ Radiology Only
____ Other (please specify)
____ Progress Note(s)
____ Operative Report
___________________________________________
The purpose for the release of information at the request of the individual is:
q Insurance
q Legal Action
q Continued Treatment
q Personal Use
q Patient Communication (Behavioral Health)
q Other (Please Specify) _______________________________________
q Family and Medical Leave Act/Disability Forms
This authorization will expire on the following date, event or condition: ____________________________________________
I understand that this authorization extends to all or any part of the records designated above, which may include psychiatric
information, and/or genetic counseling/testing, and/or alcohol/drug abuse and/or AIDS (Acquired Immunodeficiency Syndrome),
and/or may include the result of an HIV test or the fact that an HIV test was performed. I expressly consent to the release of
information as designated above unless initialed below or otherwise required by law.
May NOT include information related to (please initial):
____ HIV/AIDS
____ Mental Health
____ Drug and/or Alcohol Abuse
____ Genetic Counseling/Testing Information
If I fail to specify an expiration event or condition, the authorization will expire in one year. I understand that this authorization
is revocable upon written notice to the office where the original authorization is retained, except to the extent that action has
already been taken on this authorization. I understand that my protected health information that is used or disclosed under this
authorization may be subject to re-disclosure by the recipient and the privacy of my protected health information may no longer
be protected by law. I further understand that Orlando Health may not condition the provision of treatment, payment, enrollment
in the health plan, or eligibility for benefits on the provision of this authorization. I understand that I will receive a signed copy of
this form.
____________________________________________________________________________
_______________________________
Patient/Legal Representative or Parent/Legal Guardian Signature
Date
Time
Official Use Only: ________________________________________________________
Date:_______________________
q Name of Person Releasing Information
q Name of Person Assisting with Review
Number of pages copied _________
q I wish to revoke this authorization. Signature: ___________________________________ Date: __________________
INTERPRETER ONLY
(Please Print)
Name: ______________________________________ Agency:
Telephone:___________________________________ Language:
FORM 4856-12678 E Rev.7/13 {MR Tab #6}
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