Form Mr-109 Authorization To Release / Obtain Patient Information - The Children'S Hospital Of Philadelphia
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11-800-AEL-8888
NAME
SEX
M
F
MR#
*DTMR109*
MR-109
AEL 9/2005
AGE / DATE OF BIRTH
AUTHORIZATION TO RELEASE/OBTAIN
ACCOUNT#
PATIENT INFORMATION
(PATIENT PLATE OR PRINT)
This authorizes The Children’s Hospital of Philadelphia and its affiliates to release/obtain information as described below. For a
listing of related entities and medical practices, see The Children’s Hospital of Philadelphia Notice of Privacy Practices.
1. Patient Name (First, Middle, Last):__________________________________________________________________________
Address of Patient: _______________________________________________________________________________________
City, State, Zip: __________________________________________________________________________________________
Telephone Number:__________________________________________Date of Birth: ________________________
2. What is the name of the person or facility that will be releasing your information? Check the appropriate box below and
provide the name, address and telephone number of the person/facility releasing the information.
The Children’s Hospital of Philadelphia
I I
or
I I
Other
Name of Person / Facility:___________________________________________________________________________________
Address: _________________________________________________________________________________________________
City, State, Zip: ___________________________________________________________________________________________
Telephone Number: _______________________________________________________ Fax Number:______________________
3. What information will be released? Date of appointment or hospital stay beginning______________ through to ____________
____ Emergency Department
____ Home Care
____ Outpatient ___________________________________
____ Inpatient
____ Immunization
(please specify name of department/office)
____ Other Information (please specify)______________________________________________________________________
If there is any part of the record you do not wish released, please indicate here: ________________________________________
If your records contain any information about substance (drug or alcohol) abuse, HIV, or mental health, may this information be
released? If yes, please initial next to each type of information to be released:
Drug and/or alcohol treatment or testing __________
HIV__________
Mental Health __________
4. What is the name of the person or facility who is to receive your information? Check the appropriate box below and provide
the name, address and telephone number of the person/facility receiving the information.
The Children’s Hospital of Philadelphia
I I
or
I I
Other
Name of Person / Facility:___________________________________________________________________________________
Address: _________________________________________________________________________________________________
City, State, Zip: ___________________________________________________________________________________________
Telephone Number: _______________________________________________________ Fax Number:______________________
5.
Please explain why the person or facility above needs this information:
_____________________________________________________________________________________________________
6. Expiration. Your permission will expire 90 days after you sign this form unless you indicate otherwise. If you would like to
extend your permission for longer than 90 days, please tell us when your permission expires. The date cannot be more than a
year from now:____________________________.
7. Understanding this Authorization
• This allows the release or obtaining of information that exists in the patient’s medical record when the form is signed, as
well as information created after the form is signed until it expires.
• I may withdraw my permission at any time by providing written notice to the above-named provider releasing the information.
For information being released by The Children’s Hospital of Philadelphia, see its Notice of Privacy Practices for instructions
on how to withdraw (revoke) an authorization. If I withdraw my permission, any information that was already released cannot
be retrieved.
• Information released by The Children’s Hospital of Philadelphia may be released again by the person or organization that
receives it and is no longer protected under federal privacy laws. The Children’s Hospital of Philadelphia will protect
information it obtains as required by federal privacy laws.
• I understand my permission is voluntary and I/my child will receive treatment whether or not I sign this form.
8. Signature. By signing, I understand that I am authorizing The Children’s Hospital of Philadelphia to release/obtain information
as described above.
______________________________________
_________________________________________
___________________
Signature
Print Name
Date
Relationship to patient:
I I
Patient
I I
Parent
I I
Legal Guardian
I I
Other:________________________________
Information Released by:________________________________________________________ Date: _____________________
WHITE – MEDICAL RECORDS
YELLOW – PATIENT/PARENT/LEGAL GUARDIAN
AEL 9/2005
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