Patient Authorization For Disclosure Of Protected Health Information Form (Page 2 of 2) in pdf

Please indicate the purpose of the disclosure of your patient records:

Check here if it is for your own personal use

If applicable, I understand that based on the dates, providers, and information I have designated above; the disclosure UUHSC makes

pursuant to this authorization may include information regarding my participation in a substance abuse treatment program.

I understand that if the authorized recipient of this information is not a health care provider or health plan covered by federal privacy

regulations, the information he/she receives will no longer be protected by these regulations, and the recipient may re-disclose the

information. However, the recipient may be prohibited from disclosing substance abuse information under the Federal Substance

Abuse Confidentiality Requirements.

I understand that the University of Utah Health Sciences Center will not condition treatment, payment, enrollment or eligibility for

benefits on whether I sign this authorization. I may inspect or copy any information used or disclosed under this authorization.

I understand that I may revoke this authorization in writing at any time by sending a written revocation of authorization to: Medical

Records, 50 North Medical Drive, SLC UT 84132

I understand that my revocation is not effective to the extent that action has been taken in reliance on this authorization. This

authorization expires (check one):

1 year from the date below,

One time disclosure only,

Other:

I understand that I may be charged for this information, and I agree to be financially responsible for the charge.

Signature of Patient or Representative

Date

_________________________________________________________________________________________________________

If Applicable, Printed Name of Personal Representative

Description of Personal Representative Authority:

Parent ______

Medical Power of Attorney, ______ (attach documentation)

Other __________________________________

(Explain and attach documentation)

Signature must be verified by UHC staff OR must be notarized. When complete, place in patient’s medical record.

______________________________

________________________________

____________

Printed Employee’s Name

Signature of UHC Staff Member

Date

NOTARY PUBLIC

Name: ________________________________________________________________________________________________________

SUBSCRIBED AND SWORN before me this ____ day of ________________, 20____.

Residing in ________________________________

My Commission expires: _____________________

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Patient Authorization For Disclosure Of Protected Health Information Form Page 2