Form 46096 - Authorization To Release Medical Information Form printable pdf download

Patient Name: _____________________________________ Medical Record #:______________________

Address: _________________________________________________ Date of Birth___________________

City/State/Zip_____________________________________________ Phone:________________________

Please RELEASE Information FROM:

Please RELEASE information TO:

_________________________________

Name

______________________________________

_____________________________________

Street Address

Street Address (or specified fax number)

______________________________________

_____________________________________

City/State/Zip

______________________________________

_____________________________________

Telephone Number

______________________________________

_____________________________________

Fax Number

I AUTHORIZE THE RELEASE OF THE FOLLOWING RECORDS:

_______________________________________________________________________________________________________________________________________________

For the Purpose of:

Patient Care

Insurance Claim

Self

Other _________________________

List specific dates of records to be released: _________________________________________________

Duration: This authorization shall begin immediately and remain in effect for one (1) year unless otherwise specified as follows:

__________________ (date or event.)

The following must be INITIALED by the requestor to be included in the use and/or disclosure:

_____*HIV/AIDS related information and/or records _____Mental Health Information

_____Genetic Testing information _____**Drug/alcohol diagnostics, treatment, or referral information

*This information may not be re-disclosed without the specific written authorization of the individual, except where authorized by law.

**Federal regulation (in 42 CFR Part 2) requires a description of how much and what kind of information will be disclosed.

Restrictions: I understand that the information released may be subject to re-disclosure by the recipient and may no longer be

protected.

Rights: I understand that I may refuse to sign this authorization and that my refusal to sign may not affect my ability to obtain

treatment (see back of this form for certain exceptions). I may inspect or copy any information to be used and/or disclosed under

this authorization in accordance with organizational policy. I understand that I have the right to revoke this authorization in writing

(see back of this form). My revocation will be effective upon receipt, but will not be effective to the extent that this organization has

taken action in reliance upon this authorization.

Signature:_______________________________________________________________________________

(Patient/legal representative)

Date

Time

If signed by other than patient, indicate relationship:______________________________________________

Adventist Medical Center, Portland, Oregon

Retain in Patient Record

AUTHORIZATION TO RELEASE

MEDICAL INFORMATION: OREGON

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Authorization to Release Medical Info

46096 Rev. 2/08

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Form 46096 - Authorization To Release Medical Information Form

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