Authorization For The Release Of Protected Health Information Form

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Release of Medical Records Attachment A
RISK MANAGEMENT
Authorization for the Release of
Protected Health Information
Patient Name: ______________________________________________________
Social Security Number (last 4 digits):________________
Previous Name, if applicable: __________________________________________________
Date of Birth: ____________________________
Address: _________________________________________________City: _________________________ State: __________Zip ______________
Home Phone: ___________________________
Work Phone: ___________________________
I authorize Harbin Clinic provider _______________________________________________to release my health information which may include
treatment for drug abuse, child abuse, AIDS, alcoholism or mental illness.
RELEASE THE FOLLOWING INFORMATION:
Complete Medical Record (Please specify dates of service): From: _____________________________ to: ___________________________
q
q
Partial Medical Record (Please specify, including dates) ___________________________________________________________________
I authorize the release of billing records for the same date of service/requested record
q
SEND HEALTH INFORMATION TO:
_________________________________________________________
Name
Address: _________________________________________________________________________
City: __________________________________ State: __________ Zip _______________________
Phone Number: __________________________ Fax Number: _____________________________
Purpose
Disclosure
of
q Personal request; q Specialist Visit; q Travel Purposes; q Attorney; q Disability;
q Changing doctor; qOther: _________________________________________
Process For Release (Please allow at least five business days if picking up the record or two weeks if mailing)
q Mail to individual named above
q Mail to patient
q Call patient when information is ready for pick up (identify who will pick up the copy ______________________________________________)
Expiration Of Authorization (choose one)
*If I do not choose either of the two options below, this authorization will expire ninety (90) days from the date on which I signed this authorization.
q I understand that this authorization will automatically renew every 12 months unless I notify Harbin Clinic in writing,
q I understand that this authorization will expire on ________________________(Insert expiration date or event) unless I request
otherwise in writing.
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