Authorization For Release Of Medical Information Form

ADVERTISEMENT

AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION
____________________________________________
__________________________________________
(Print patient’s full name)
Birth date (Mo/Day/Yr)
____________________________________________
__________________________________________
(Street address)
Social Security Number
____________________________________________
___________________________________________
(City, state, zip code)
Phone (Home)
At the request of the individual, I ___________________________, do hereby authorize _____________________________
(Patient Name)
(Practice Name)
_________________________________to release:
_____Medical History
_____Radiology Reports
_____Immunization Records
_____Progress Notes
_____EKG Results
Other_________________________
_____Laboratory Reports
_____Other Ancillary Reports
_________________________
_____I do
_____I do NOT
authorize release of information related to AIDS (Acquired Immunodeficiency Syndrome) or HIV
(Human Immunodeficiency Virus) Infection, psychiatric care and/or psychological assessment,
and treatment for alcohol and/or drug abuse.
INFORMATION RELEASE TO:
____________________________________________
Name of Company/Agency/Facility/Person
____________________________________________
Street address
_____________________________________________
City, state, zip
PURPOSE OF DISCLOSURE:
_____REFERRAL TO SPECIALIST
_____INSURANCE
_____WORKERS COMP
_____CHANGE OF DOCTOR
_____LEGAL INVESTIGATION
_____DISABILITY DETERMINATION
_____PERSONAL
OTHER (SPECIFY)______________________________________________________________________________________
Please provide a DAYTIME telephone number in the event we need to contact you:________________________________
I hereby authorize disclosure of the health information for the above named patient. This authorization is valid for 90 DAYS from the
date of signature. I understand that I may cancel this request with written notification but that it will not affect any information
released prior to notification of cancellation. I understand that the information used or disclosed may be subject to re-disclosure by the
person or class of persons or facility receiving it, and would then no longer be protected by federal regulations. I understand that the
medical provider to whom this is authorized is furnished may not condition its treatment of me on whether or not I sign the
authorization.
_______________________________________________
______________________________________
Signature of individual (or guardian or Personal
Date
Representative of patient’s estate)
MEDICAL INFORMATION RELEASED
Medical History______
Radiology Reports_____
Immunization Records_____
____________________________
Progress Notes_______
EKG Results__________ Other_________________________
ROI SPECIALIST
Lab Reports__________ Other Ancillary Rpts____
_________________________
____________________________
DATE
A PHOTOCOPY OF THIS RELEASE IS VALID AS THE ORIGINAL.

ADVERTISEMENT

00 votes

Related Articles

Top 20 Happy Easter Cards And Gift Tags To Download For Free
Top Ten Easter Arts And Crafts Activities For Your Kids
Free Easter Coloring Pages And Easter Printables For Your Kids

Related forms

Authorization For Release Of Medical Information Form Authorization For Release Of Medical Information Form Business
Authorization For Release Of Medical Information Form Authorization For Release Of Medical Information Form Business
Authorization For Release Of Medical Information Form Authorization For Release Of Medical Information Form Business
Hipaa Compliant Authorization For Release Of Medical Information Form Hipaa Compliant Authorization For Release Of Medical Information Form Business
Treating Physician Information Form/authorization For Release Of Medical Records Form - September 11th Victim Compensation Fund - Treating Physician Information Form/authorization For Release Of Medical Records Form - September 11th Victim Compensation Fund - Legal
Occupational Medicine Exam Request Form And Authorization For Release Of Medical Information Occupational Medicine Exam Request Form And Authorization For Release Of Medical Information Medical
Patient Authorization For Release Of Medical Information To Third Party Form Patient Authorization For Release Of Medical Information To Third Party Form Legal
Authorization For Disclosure And Release Of Medical Information Form Authorization For Disclosure And Release Of Medical Information Form Legal
Authorization For Release Of Medical Record Information Form Authorization For Release Of Medical Record Information Form Business
Authorization Form For Release Of Medical Information Authorization Form For Release Of Medical Information Business

Related Categories

Parent category: Business
Download
Go