Authorization For Use & Disclosure (Release) Of Protected Health Information Form - Cook Children'S Health Care System (Cchcs) Page 2

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This form, if signed, will authorize Cook Children's Health Care System (CCHCS) to use and release certain health information about
the person named below. All items must be completed and the authorization signed and dated by an authorized person to be valid. I
understand this authorization is voluntary, I may refuse to sign this authorization and I understand that CCHCS may not withhold
treatment because I refuse to sign this authorization.
1. I authorize CCHCS (check (√) one or more:
Medical Center
Physician Name/Clinic Name: _____________________
___________________________________
Home Health
to release health information, as described below, from the
medical record of:
Patient’s Full Name: ____________________________________________________ Date of Birth: ____________________
2. The information specified below may be released to:
Name/Company: ___________________________________________________________________________________________
Address: _________________________________________________________ Telephone: ______________________________
City: _______________________________________________State: ____________________ Zip: ________________________
3. The specific purpose(s) for this disclosure is/are [check (√) your selection(s)]:
my personal records;
share with other
healthcare providers as needed;
social security /disability;
military;
education:
other (please describe)
____________________________________________________________________________________________________
4. Must select one:
I want OR
I do not want the specified information to be released to include history, diagnosis and/or
treatment for: HIV/AIDS/testing, Communicable diseases, Drugs/Alcohol, Mental Health disease.
5. SPECIFY EXACT INFORMATION TO BE RELEASED: (1) Place a check (√) next to the specific medical information to be
released, (2) list the specific dates of treatment, and (3) list the physician or clinic name if physician office records are requested:
√ INFORMATION
√ INFORMATION
DATES OF SERVICE
DATES OF SERVICE
Hospitalization Reports (most
Immunization Information/
pertinent information)
Other Test Results
Discharge Summary
Psychological Evaluation
History & Physical
Operative Report
Emergency/Urgent Care
Consultation
Lab
Specialty Clinic Notes:
X-ray report
Audio, PT, OT, Speech Evaluation (s)
X-ray images
Other:
Approve verbal communication with: ______________________________ for visit date: ______________Initial: ____________
6.
I understand and acknowledge the following statements:
I may be asked to show proof that I have the authority to sign an
authorization to review, receive or release to another party copies of the above named patient’s medical record which I am requesting. In order to
inspect or receive a copy of the medical record for myself, I must complete and sign this authorization form. If I request to do so, I may inspect the
medical information to be released to another party after signing this form. Unless required or allowed by law, the medical information will not be
released to another party, if, after inspecting the medical information, I revoke this authorization prior to the release of the medical information. After
the above medical information is released, it may be re-released by the recipient and the information may no longer be protected by federal privacy
laws or regulations. A facsimile or photocopy of this authorization is as valid as the original. I will be charged a fee for any copies of my medical
records or my child’s medical record I request for myself or for use by others. Fees for copies are due and payable before copies are released. I may
revoke this authorization at any time by notifying CCHCS in writing to ATTN: Cook Children's Health Care System, Medical Record Department,
of my intent to revoke this authorization, except that if I do notify CCHCS in writing of my intent to revoke this authorization, such revocation will
not have any affect on any actions by CCHCS taken before the revocation. Unless otherwise revoked in writing, this authorization will EXPIRE 180
DAYS from the date this form is signed.
7.
____________
________________________________________________________________
______________________
DATE
Signature of Patient, Parent or Legally Authorized Representative
Relationship to Patient
8. ___________________________________________________________________
____________________________
Printed Name of Parent or Legally Authorized Representative
Patient ID Number (Office use only)
(NOTE: All items in this authorization must be completed to be valid and executable)
AUTHORIZATION FOR USE & DISCLOSURE (RELEASE) OF PROTECTED HEALTH INFORMATION
v0812

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