Form Nonch35557 - Authorization For The Release Of Protected Health Information - Emory Healthcare Page 2
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1
2medical record number: ____________________________
(for internal purposes)
5.
E
a
xPiration oF
utHorization
unless i request in writing otherwise, i understand that this authorization will expire on ______________________________
(Insert expiration date or event). if i do not specify an expiration date or event, this authorization will expire ninety (90) days
from the date on which i signed this authorization.
6.
r
r
a
igHt to
EvokE
utHorization
i understand that i have a right to revoke this authorization at any time. i understand that if i revoke this authorization, i
must do so in writing and present my written revocation to the medical records department(s) of the emory healthcare
facility or facilities checked above. A list of addresses for the medical records departments is contained in the emory
healthcare, inc. notice of Privacy Practices. i understand that the revocation will not apply to any health information that
has already been released in response to this authorization.
7.
r
-
E
DisclosurE
i understand that if my health information is disclosed to a party other than a health care provider, health plan or health
care clearinghouse subject to the federal privacy regulations, my health information disclosed pursuant to this authorization
may no longer be protected by the federal privacy regulations.
8.
F
EEs
i understand that federal and state laws allow a fee to be charged for the copying of patient records and i will be responsible
for the payment of such fees.
9.
r
a
u
/
D
EFusal to
utHorizE
sE anD
or
isclosurE
if i have been asked to sign this form in order to authorize the disclosure of my health information for purposes related to
research, or for other reasons, i understand that emory healthcare may decline to treat me if i refuse to sign this authorization
only if: (1) the treatment would be related to a research project and this authorization is for the use or disclosure of my health
information such research; or (2) the treatment would be for the sole purpose of creating health information for disclosure
to a third party (such as a workers compensation examination).
10.
r
W
ElEasE anD
aivEr
if the health information that i have requested emory healthcare to disclose contains any privileged psychiatric or
psychological information related to the treatment of physical and/or mental illness, chemical dependency or alcohol abuse,
or testing or treatment of any communicable or infectious disease such as acquired immunodeficiency syndrome (Aids),
immunodeficiency syndrome related complex (Arc), human immunodeficiency virus (hiV), Venereal disease,
tuberculosis, or hepatitis, i hereby waive any privilege concerning such information for the purpose(s) of releasing it to the
party or parties authorized above. i also release emory healthcare, each of the emory healthcare facilities checked above,
and their officers, trustees, agents and employees from any and all liabilities, damages and claims, which might arise from the
release of the health information authorized by me above.
_______________________________________________
______________________
_______________________
signature of Patient (or Patient’s representative)
date
time
_______________________________________________
______________________________________________________
Printed name
description of Authority to Act for Patient
NOte: a COpy Of this COmpleted, sigNed aNd dated fORm must be pROvided tO the patieNt aNd/OR
patieNt’s RepReseNtative aNd a COpy must be plaCed iN the patieNt’s mediCal ReCORd
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