Form Rec-48 Authorization To Release Protected Health Information
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2AUTHORIZATION TO RELEASE PROTECTED HEALTH INFORMATION
PATIENT INFORMATION:
Name of Pa ent/Previous Names
Birth Date
Medical Record Number
Street Address
City, State, Zip
Phone Number
AUTHORIZES DISCLOSURE BY:
ProHealth Care Oconomowoc Memorial Hospital
ProHealth Care Waukesha Memorial Hospital
ProHealth Care Behavioral Health Services
ProHealth Works, Specify Site _____________________
PHMG, Specify Clinic/Provider _________________
ProHealth Solu ons Par cipant____________________
Other (Name of Health Care Provider/Plan/Other): _______________________________________________
Street Address_______________________________________ City, State, Zip Code______________________
DISCLOSURE OF HEALTH INFORMATION TO:
Name of Health Care Provider/Plan/Other________________________________________________________
Street Address _______________________________
City, State, Zip Code_________________________
INFORMATION TO BE DISCLOSED:
CLINIC
HOSPITAL
Clinic Records 2-3 Year Summary (general abstract
Hospital Summary (general abstract includes
includes Progress Notes, Consults, Labs & Radiology
Discharge Summary, H&P, Consults, Opera ve Reports,
Reports)
Labs, Radiology Reports and ED Report)
Mental/Behavioral
Mental/Behavioral
En re Medical Record
En re Medical Record
Health
Health
History & Physical
Radiology Films
History & Physical
Radiology Films
Offi ce Visit Notes
Radiology Report
Consulta on
Radiology Report
Opera ve/Procedure
Rehab Notes (PT, OT,
Opera ve/Procedure
Rehab Notes (PT, OT,
Report
Speech)
Report
Speech)
Laboratory Report
Billing Records
Discharge Summary
Billing Records
Pathology Report
Laboratory Report
Pathology Report
Other _____________________________________
Other ______________________________________
DISCLOSURES REQUIRING SPECIAL CONSENT: In compliance with Wisconsin Statutes which require special permission
to disclose otherwise privileged informa on, I am authorizing that the following informa on also be disclosed.
Check all that apply.
HIV/AIDS*
Drug/Alcohol Abuse/Treatment
SANE
SANE Photos
FOR THE FOLLOWING DATES: From: __________________ To: ________________________
PURPOSE FOR DISCLOSURE: Please provide specifi c purpose for disclosure or check applicable category.
Con nuing Care
Transfer to New Provider
Insurance/Claim Purposes
Legal
Personal Use
Disability Determina on
Workers Compensa on
Voca onal Rehab Eval
Other
Check One:
Verbal Release
Paper Release
View
Electronic/Digital Release (specify)
Release by:
US Mail
MyChart
Fax ____________
Pick-Up: Loca on
PATIENT LABEL
FRONT
REC-48
507 AUTHORIZATION
DAROI
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Parent category: Business