Patient Authorization For Disclosure Of Protected Health Information Form printable pdf download

Patient Authorization For Disclosure Of Protected Health Information Form

PATIENT AUTHORIZATION

FOR DISCLOSURE OF PROTECTED HEALTH INFORMATION

PATIENT INFORMATION

Patient Name

Medical Record #

Date of Birth

Phone # (

)

Patient Address

Patient E-Mail Address _______________________________________________________________________

Soc. Sec. #

(Providing your SS# is voluntary, but necessary to accurately

identify your medical records, if your Medical Record Number is not provided.) Failure to provide this

information will likely delay the processing of your request.

Approximate Dates of Treatment:

Information to be Disclosed

I authorize the following health care provider(s) to DISCLOSE my patient information:

____________________________________________

_____________________________________

____________________________________________

_____________________________________

Please include the following (circle to indicate your selection):

Full Record (check record volume with Health Information Representative)

History and Physical

Psychological Evaluation

Discharge Summary

Emergency Records

Radiology and Lab Reports

Outpatient Clinical Records

Psychosocial History

Consultation Reports

Immunizations

Operative Report

Other:

Please provide records in the following format:

_____ On Paper*

_____ CD Rom (provided by UUHSC)

_____Thumb Drive (provided by UUHSC at cost)

NOTE: There may be a cost if copies number more than 10 pages.

Recipient Information

I authorize the following person(s) or organization TO RECEIVE my patient information:

Name:

Relationship:

Address:

Phone #

Name:

Relationship:

Address:

Phone #

*RELEASE OF INFORMATION*

UUH-SC 1025/R12-12

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Patient Authorization For Disclosure Of Protected Health Information Form

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