Hipaa Compliant Authorization To Release Healthcare Information Form printable pdf download

Hipaa Compliant Authorization To Release Healthcare Information Form

Anthem Hills Pediatrics

HIPAA COMPLIANT AUTHORIZATION TO RELEASE

HEALTHCARE INFORMATION

Patient Name __________________________________________________________________

Date of Birth _______________________ Social Security Number _______________________

Address ______________________________________ State ___________ Zip ____________

I authorize the use or disclose the above named individuals’ PHI to be released as follows:

_____ Medical Record

_____ Xrays

_____ Immunizations

_____ Other

Reason for request:

_____ Continuing Care

_____ Personal

_____ Insurance

_____ Attorney

_____ Other

Transfer Records From:

Name ________________________________________________________________________

Address __________________________________________ State ___________ Zip _________

Phone ____________________________ Fax _______________________________

Transfer Records To:

Name ________________________________________________________________________

Address __________________________________________ State ___________ Zip _________

Phone ____________________________ Fax _______________________________

There is a fee to release medical records to a legal parent or guardian. If a hard copy is

requested it is .60 per page. If records are scanned to a disk it is $10.00.

I may revoke this authorization in writing. If I do, it will not affect any previous actions already taken in reliance

upon my authorization. I may not be able to revoke this authorization if its’ purpose was to obtain insurance. I

may revoke this authorization by writing a letter and mailing it certified mail, return receipt requested to the

Privacy Officer at the health care provider listed above.

Information used to disclose pursuant to this

authorization may be subject to re-disclosure by the recipient and no longer protected by Federal privacy

regulations.

This authorization is valid for _______days or one year from the date signed. Only the records from this facility

can legally be released. Any record from another physician must be obtained from them.

______________________________________________

________________

Signature Patient/Guardian

Date

Updated May 16, 2014

Hipaa Compliant Authorization To Release Healthcare Information Form