Authorization Form For Release Of Health Information Form - Planned Parenthood Of The St Louis Region & Southwest Missouri Page 2
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2HEALTH INFORMATION TO BE RELEASED:
I specifically authorize release of the following information indicated in the box(s) checked
below:
I UNDERSTAND THAT THE MOST RECENT WILL BE SENT UNLESS I HAVE
WRITTEN A SPECIFIC DATE(S) BELOW
DATE(S)
Summary of visit (history/exam/progress & visit notes) ____________
Lab reports
____________
Ultra Sound
____________
HIV test results
____________
STI (sexually transmitted infection) test results
____________
Prescribed medication information
____________
Other: ________________________________
____________
Entire Medical Record ($25.00 fee for paper records)
____________
I request this information to be forwarded electronically if the party can receive it that way
This Request and Authorization is made for the following purpose:
___ To share information between health care providers who plan to or already have initiated or
continue my care.
___ Other—Specify reason ___________________________________________________________
CONDITIONS OF AUTHORIZATION
1.
This Authorization will expire on (insert date or event, generally 6 months out) ________________________
2.
I may revoke this Authorization at any time by notifying Planned Parenthood of the St. Louis Region &
Southwest Missouri in writing, and it will be effective on the date notified except to the extent that Planned
Parenthood of the St. Louis Region & Southwest Missouri has already acted upon such Authorization.
3.
Information used or disclosed pursuant to this Authorization may be subject to re-disclosure by the recipient
and no longer protected by Federal privacy regulations.
4.
By authorizing this release of information, my healthcare and payment for my healthcare will not be affected if I
do not sign this Authorization form.
5.
I have been offered a copy of this signed Authorization form.
6.
If this authorization is for Marketing, I have been informed that Planned Parenthood of St. Louis Region &
Southwest Missouri: ___ will ___will not receive financial or in-kind compensation in exchange for using or
disclosing the health information described above.
_______________________________________ OR ______________________________________________
SIGNATURE OF PATIENT
DATE
PARENT/LEGAL GUARDIAN/AUTHORIZED PERSON
DATE
FOR OFFICE USE ONLY
DATE REQUEST FILLED: _________________________________ BY: _______________________________________________
IDENTIFICATION PRESENTED: ___________________________
FORM OF IDENTIFICATION: ____________________
Patient Printed Name________________________________________ DOB______ MRN_________
Z:\FORMS\RE19p_Release and RequestAutorizationForm_2014_07_10.doc
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