Authorization For The Disclosure Of Health Information Form
Download a blank fillable Authorization For The Disclosure Of Health Information Form in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Authorization For The Disclosure Of Health Information Form with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1University of Minnesota, Duluth Health Services
615 Niagara Court, Duluth, MN 55812
Reception - (218) 726-8155
(218) 726-6132 Fax
Nurse’s Station - (218)726-7863
(218) 726-8515 Fax
Authorization for Disclosure of Health Information
PLEASE PRINT
Patient Name: _____________________________________ Date of Birth: ______________UMD ID#________________
I hereby authorize:
( ) Disclose to
( ) Obtain from ( ) Exchange with
UMD Health Services
615 Niagara Court
Facility / Organization
Duluth, MN 55812-3065
Address
City / State/ Zip Code
(
)
(
)
Phone Number including area code
Fax Number including area code
PURPOSE OF DISCLOSURE:
I specifically authorize the release of information relating to:
(
) Transfer to another clinic
(
) Psychological Health
(
) Continued Care
(
) Substance abuse (including alcohol/chemical use)
(
) Personal Use
(
) Sexually transmitted infections
(
) Other ___________________
(
) HIV related information (AIDS related testing)
________________________
_____________________________________
___________
Signature of Patient or Legal Representative
Date
SPECIFIC INFORMATION TO BE
RELEASED:
(
) Any and all Medical Records
(
) Conversations between providers
(
) History and physical
(
) Immunization Records
(
) Progress/Provider Notes
(
) Diagnosis / Treatment Plan
(
) Laboratory Reports/X-ray reports
(
) Other
(
) Recent pap/pelvic/PE/OCP records/Depo injections
(
) Records regarding treatment for
(Specific Condition or Injury)
DATES OF INFORMATION TO BE RELEASED:
From _____ / _____ / _____ to _____ / _____ / _____
May Information Be Sent By FAX: (
) Yes
(
) No
Signature
Information regarding this authorization:
-
Each transfer of Medical Records requires a new release form signed by the patient.
-
This form allows exchange of Counseling/Mental Health Records for one year.
-
I may revoke this consent at any time by providing UMD Health Services with a written statement specifically revoking
this authorization.
-
I will receive a copy of this authorization form upon my request.
-
By authorizing the use or disclosure of information, there will be no conditions placed on my health care.
-
Information disclosed by this authorization may be subject to redisclosure by the recipient and no longer protected by
Federal privacy regulations.
-
In compliance with MN Statue 144.33, I may be required to pay a fee for retrieval and photocopying of records and/or a
supervised inspection of medical records.
I have reviewed and understand the content of this authorization form. By signing this authorization I am confirming that it
accurately reflects my wishes.
Signature of Patient or Legal Representative
Date
Authorization for Disclosure.0413.doc
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal