Authorization For Release Of Medical Information Form printable pdf download

Medical

Record

Number ___________________

AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION

Name of Patient: ________________________________________________________ Date of Birth: ____________________

Number to call (_____) ______ - ________ Call when ready? (circle) yes no

(Circle) Email Fax Mail

Pick-up

Date of Request: _________________

Date Needed: ___________________

Number to fax (_____) _____-___________

I authorize the use or disclosure of the above named individual’s health information, its employees and agents, to furnish:

RECORDS COMING FROM:

RECORDS GOING TO:

Blessing Hospital

Blessing Physician Services

Name: __________________________________________________

Blessing Walk-In

Illini Community Hospital

Address: _________________________________________________

c/o Health Information Management

Telephone: _____________________ Fax: ______________________

Telephone: 217-223-8400 x 6600 Fax: 217-214-5890

Email:

_________________________________________________

The type of information to be used or disclosed is as follows (check all of the appropriate boxes and details as needed):

Dates of Service/Treatment (include specific dates or date range):

HOSPITAL SETTING

Continuing Care Abstract (includes all Physician dictation & Radiology, Lab and Cardiology reports)

Discharge Summary

Laboratory and Pathology Reports

Mental Health Records

History and Physical

Cardiology Reports (EKG, ECHO, Cath, etc)

Psychological Testing

Consultations

X-ray Reports

Clinic Notes (Wound, Pain)

Operative Reports

X-ray Films

Itemized Bill

Emergency Department Records

Therapy Notes (PT, ST, OT, Radiation, etc)

Entire Record for dates listed

Other (please specify): ______________________________________________________________________________

OFFICE SETTING

Office Notes

Immunization Records

Entire Record for dates of service

Laboratory Reports

Physical Forms

Workability or School Release forms

Itemized Bill

Mental Health Records

Other (please specify): ________________________________________________

I understand that the information in my health record may include information relating to sexually transmitted disease, genetic testing, acquired

immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV). It may also include information about behavioral or mental health services

even though I am protected by Federal regulations governing Confidentiality of Alcohol and Drug Abuse Patients Records, 42 CFR Part 2, the Illinois AIDS

Confidentiality Act, or the Mental Health and Developmental Disabilities Confidentiality Act. A request in writing must be made to exclude the above from

the disclosed information.

I understand photo identification may be required to obtain medical records.

The purpose for which this disclosure is being made is:

My personal records

Sharing with other healthcare providers

Other (please describe) __________________________________________________________________________

I understand that I have the 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 Health Information Management Department. I understand that the revocation will not apply to information that has already

been released in response to this authorization.

I understand that once the above information is disclosed, it may be re-disclosed by the recipient and the information may not be protected by federal privacy

laws or regulations. In accordance with the Mental Health Code – No person or agency to whom any information is disclosed may re-disclose such

information unless the person who consented to the disclosure specifically consents to such re-disclosure. I understand that I have the right to inspect and

copy the information that is to be disclosed.

This Authorization expires on: __________________________________. If I fail to specify an expiration date, this authorization will expire six months from

date of signature.

I understand authorizing the use or disclosure of the information identified above is voluntary. Healthcare treatment, payment, enrollment in the health plan,

or eligibility for benefits is not conditioned on signing the authorization. Beyond this, my refusal to consent may have the following consequence – failure to

disclose information. Electronic images/records (ie Radiology) on CD/USB media are not encrypted or password-protected and are the sole responsibility of

the recipient of the records to protect from unauthorized viewing. Unencrypted CD/USB media cannot be mailed by Blessing.

_____________________________ ______________

_____________________________________ ____________

Witness

Date

Signature of Patient or Legal Representative

Date

_____________________________ _______________

Legal Representative Relationship (POA) __________________

Minor Age 12 to 17

Date

This Authorization must be signed by the patient or guardian if patient is less than 12. In keeping with the Mental Health & Services Disability

Confidentiality Act, if the patient is a minor and recipient is 12 years of age or older, then this authorization must be signed by the patient. If the patient is

mentally incompetent and over the age of 18, this Authorization must be signed by the appointed legal representative of the patient.

BCS100/0100spd

Revised 8/2015