Form Mr-465-8 Nis-Authorization For Disclosure Of Health Information Form Page 2
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2AUTHORIZATION FOR DISCLOSURE OF
LABEL
HEALTH INFORMATION
AGNESIAN HEALTHCARE
MR-465-8 NIS (5/2/14)
ORDER FROM PRINTING
5.
Specific type of health information to be disclosed:
❑ All health records (last 2 years)
❑ Progress Notes
❑ Discharge Summary
❑ Medications
❑ History & Physical
❑ Therapy Notes
❑ Outpatient Report
❑ Condition Updates
❑ Lab Reports
❑ Vision Records
❑ Immunization Record
________________________________________________________
❑ Medical Imaging:
❑ Other (specify):
___________________________________________________________________
❑ CD
❑ Reports
❑ Echo
Health information protected by federal confidentiality rules (42CRF part 2)
❑ BH Diagnoses
❑ BH Mental status exam
❑ BH Attendance
❑ Psychological testing
❑ Drug/alcohol history
❑ BH Physical exam
❑ Psychiatric history
❑ BH Medication management
❑ BH Treatment summary or plan ❑ BH Initial intake/assessment ❑ BH Discharge/summary transfer
❑ Psychotherapy notes
❑ AODA
❑ Hepatitis B
❑ AIDS
(acquited immune deficiency syndrome)
❑ HIV infection
❑ TB (tuberculosis)
❑ STD
❑ Sickle cell anemia
(sexually transmitted disease(s)
❑ Other: _______________________________________________________________________________________________________
6.
Date(s) of health information to be disclosed and/or chronic condition: _________________________________________________
________________________________________________
___________________________________________
________________________________________________
___________________________________________
7.
Disclosure may be in the form of: ❑ Photocopies
❑ Fax
❑ Verbal communication
❑ Inspection
❑ Written correspondence
8.
Purpose or need for disclosure:
❑ Continuity of care
❑ Personal use
❑ Second opinion
❑ Payment of insurance claim
❑ Application for insurance
❑ Legal investigation
❑ Disability determination
____________________________________________________________________________________________
❑ Other
9.
I understand that this authorization may be revoked by me at anytime (except that the facility has already acted in reliance on it) by written
notice to the appropriate Health Information Management Department. I have the right to inspect and receive a copy of the material to be dis-
closed and receive a copy of the informed consent. This consent will remain in effect until the above request is processed or unless otherwise
specified. When health information is disclosed to anyone except a covered facility it would no longer be protected under HIPAA (Health Insur-
ance Portability and Accountability Act of 1996) regulations. Signing this authorization is voluntary and I may refuse to sign. Unless allowed
by law, my refusal to sign this authorization will not affect my ability to obtain treatment, receive payment or eligibility for benefits.
Prohibition of Disclosure: This information has been disclosed to you from records protected by Federal confidentiality rules (42 CFR
Part 2 and Wisconsin Statute 51.30). The Federal rules prohibit you from making any further disclosure of this information unless further
disclosure is expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42 CFR Part 2. A
general authorization for the release of medical or other information is NOT sufficient for this purpose. The Federal rules restrict any use of
the information to criminally investigate or prosecute any alcohol or drug abuse patient. I understand I may inspect and receive a copy of the
disclosed information.
10.
I understand that a photocopy of this consent is as valid as the original. This consent is valid for a period of one (1) year.
__________________________________________________
_______________
11.
Signature of Patient:
Date & Time Signed:
112. If signed by person other than the patient, complete the following:
Patient is: ❑ minor
❑ incompetent
❑ disabled
❑ deceased
Legal authority: ❑ parent of minor*
❑ legal guardian
❑ next of kin of deceased
❑ Power of Attorney for HealthCare
(attach POA document)
*For minors: Are you the parent of the child? ❑ yes ❑ no
If so, have you ever been denied custody of this child? ❑ yes ❑ no
__________________________________________
Signature of person legally authorized:
_____________________________ Time: ______________
Date signed:
OFFICE USE ONLY
Date of request: ______________________
Records sent:_____________________________________________________________
Copies by: _______________________________________________________________
Initials: _________________ Date: _________________________Time: ______________
Released to:___________________________________________
Patient’s charge for records: ______________________________
This information was:
❑ Hand carried by patient
❑ Hand carried by
❑ Mailed first class
❑ Express mailed
❑ Fax
❑ Other: ______________________________________________
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