Form Rec-48 Authorization To Release Protected Health Information Page 2
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2AUTHORIZATION TO RELEASE PROTECTED HEALTH INFORMATION
YOUR RIGHTS WITH RESPECT TO THIS AUTHORIZATION:
Right to Inspect or Receive a Copy of the Health Informa on to Be Used or Disclosed – I understand that I have the
right to inspect or receive a copy (may be provided at a reasonable fee) of the health informa on I have authorized to
be used or disclosed by this authoriza on form.
Right to Receive Copy of This Authoriza on – I understand that if I agree to sign this authoriza on, I may receive a
copy.
Right to Refuse to Sign This Authoriza on – I understand that I am under no obliga on to sign this form and that
ProHealth Care may not condi on treatment, payment, enrollment in a health plan or eligibility for health care benefi ts
on my decision to sign this authoriza on except regarding a) research related treatment, b) health plan enrollment or
eligibility, c) the provision of health care that is solely for the purpose of crea ng PHI for disclosure to a third party.
Right to Withdraw This Authoriza on – I understand that I have the right to withdraw this authoriza on at any me by
providing a wri en statement of withdrawal to ProHealth Care’s Release of Informa on Department. I am aware that
my withdrawal will not be eff ec ve as to uses and/or disclosures of my health informa on that the person(s) and or
organiza ons(s) listed above have already made in reference to this authoriza on. I understand that informa on used
or disclosed pursuant to this authoriza on may be subject to redisclosure and no longer protected by Federal privacy
standards.
*HIV Test Results: I understand my HIV test results may be released without authoriza on to persons/organiza ons
that have access under State laws and a list of those persons/organiza ons is available upon request.
Copy or Facsimile (FAX) Valid as an Original.
This informa on has been disclosed to you from records protected by Federal confi den ality rules (42 CFR part 2).
The Federal rules prohibit you from making any further disclosure of this informa on unless further disclosure is
expressly permi ed by the wri en consent of the person to whom it pertains or as otherwise permi ed by 42 CFR
part 2. A general authoriza on for the release of medical or other informa on is NOT suffi cient for this purpose.
The Federal rules restrict any use of the informa on to criminally inves gate or prosecute any alcohol or drug abuse
pa ent.
EXPIRATION DATE: This authoriza on is eff ec ve un l ____________________________ or 6 months from the date
signed, and includes records that were created or existed on or before the date this authoriza on was signed.
This includes records that are created a er the date this authoriza on is signed, up un l the expira on date.
______(ini als)
SIGNATURE OF PATIENT/LEGAL REP: ____________________________________ DATE: ___________ TIME: ______
If signed by a person other than the pa ent, complete the following:
1. Individual is:
a minor
legally incompetent or incapacitated
deceased
2. Legal authority:
parent*
legal guardian
next of kin/executor of deceased
ac vated POA for
Health Care
*By signing above, I hereby declare that I have not been denied physical placement of this minor child.
_______________________________________________________________________________________________
Informa on Released By: ____________________________________ DATE: ____________ TIME: _______
Number of Pages Released: __________
PATIENT LABEL
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REC-48
507 AUTHORIZATION
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