Authorization For Release Of Patient Health Information Form

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Patient Name
________________________________________________________
Address
______________________________________________________________
Phone Number
_______________________________________________________
Date of Birth
_________________________________________________________
Medical Record Number
______________________________________________
AUTHORIZATION FOR RELEASE OF PATIENT HEALTH INFORMATION
I hereby authorize that the protected health information regarding the above-named person be forwarded:
FROM:
Person/Institution______________________________________________________________________________
Address______________________________________________________________________________________
City__________________________________________________State_________________Zip_______________
TO:
Person/Institution_______________________________________________________________________________
(Recipient)
Address_______________________________________________________________________________________
City___________________________________________________State________________Zip________________
Purpose or need for information:_________________________________________________________________________________________
Disclosure will include: (check all that apply)
Itemized Bill
Face Sheet
History & Physical
Laboratory Report
Operative Report
Discharge Summary
Progress/Physician Notes
X-ray/Radiology Report
Pathology Report
Other ________________
Emergency Report
Nurses Notes
EKG/EMG/EEG Report
Consultation Report
Records for the period (dates) from ____________________________________to__________________________________________
I must check one or more of the following types of health information that I do not want released to the above named Recipient.
I understand that if I do not check any of the three (3) following boxes, the health information released to the named Recipient
may include any of the following:
______Diagnosis, Evaluation and/or treatment for alcohol and/or drug abuse
______Records of HTLV-III or HIV testing (AIDS test) result, diagnosis and/or treatment
______Psychiatric, psychological records or evaluation and/or treatment for mental, physical and/or emotional illness including
narrative summary, tests, social work assessment, medication, psychiatric examination, progress notes, consultations,
treatment plans, and/or evaluation.
I also understand that this Authorization is subject to revocation/withdrawal by me at any time in writing to the medical record contact person at this site of care
except to the extent that action has already been taken to release this information. This Authorization shall remain valid unless revoked but will expire in 1 year
after signing. I have a right to inspect a copy of the health information to be released and if I do not sign this Authorization, the institution named above will not
release my health information. The above named person/institution will not refuse to treat me based on whether I agree to allow my health information to be used
and disclosed to others.
____________________________________________
___________________________
Date
Signature of Patient
____________________________________________
___________________________
Relationship to Patient
Signature of Parent/Legal Guardian/Personal Representative
(Required if Patient is not legally authorized to sign Authorization)
_______________________________________________
Witness
REDISCLOSURE:
Notice is hereby given to the patient or legal representative signing this Authorization that Advocate Health Care cannot guarantee that
the Recipient receiving the requested health information will not redisclose any or all of it to others. Notice is hereby given to the Recipient that law prohibits the
redisclosure of any health information regarding drug and/or alcohol abuse, HIV and mental health treatment.
White - Original in the Medical Record
Yellow - Copy to the Patient
98-5050-EN

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