Authorisation To Release Protected Health Information Form printable pdf download

Authorization to Disclose Protected Health Information

The undersigned authorizes

CHATHAM ORTHOPAEDIC ASSOCIATES, P.A.

4425 PAULSEN STREET SAVANNAH, GA 31405

Ph. 912‐355‐6615 option # 8  Fx. 912‐721‐2078

to release my health information as noted below

Patient Information

Patient Full Name: __________________________________ Other Names? _________________________

Patient Address: ________________________________________ Date of Birth: ______________________

City: ______________________ State: ______ Zip: ___________ Phone #: _________________________

Release Information To

Name/Facility: __________________________________ Attention: _________________________

Address: _______________________________________ Phone: ____________________________

City: _________________ State: ______ Zip: ________ Fax #: _________________________

Email: _________________________________________

(Patient’s Only – Please ensure email address is legible!)

Purpose of Request:  Personal  Treatment  Legal  Insurance  Transfer  Other:____________

Please forward Records by:  Mail  Fax (for Dr’s Offices)  Email (For Patients)

Information to be Released

If you fail to specify, a 1 year abstract will be provided.

I understand I will be responsible for the charges

 Please release a 1 year abstract of my records (includes

incurred in the release of my protected health

most recent notes, labs, & testing)

information. See GA Code §31‐33‐3

 Please release a 2 year abstract of my records

Copy fee: $0.97 per page for pages 1‐20, $0.83 per page

 Please release my entire record.

for pages 21‐100, $0.66 per page, thereafter. Postage, if

 Other (please specify): ____________________________

applicable. Records being sent to another healthcare

______________________________________________

provider will be provided at no cost.

Authorization to Release Protected Health Information

I acknowledge and hereby consent to such, that the released information may contain alcohol, drug abuse,

psychiatric, HIV testing, HIV results, or AIDS information.* ___________ (Please Initial)

I understand that:

1. I may refuse to sign this authorization and that it is strictly voluntary.

2. My treatment, payment, enrollment or eligibility for benefits may not be conditioned on signing this authorization.

3. I may revoke this authorization at any time in writing, but if I do, it will not have any effect on any actions taken prior

to receiving the revocation. Unless otherwise revoked, this authorization will expire on the following date, event or

condition: _______________________________.

If I do not specify expiration this authorization will expire in 90 days.

4. If the requestor or receiver is not a health plan or health care provider, the released information may no longer be

protected by federal privacy regulations and may be disclosed.

5. I understand that I may see and obtain a copy of the information described on this form, for a reasonable copy fee, if I

ask for it. I can request a copy of this form after I sign and date it.

Please confirm that you have filled out this form in its entirety—if form is incomplete, or if protected

information is not released, we may be unable to fulfill this request.

Signature*:__________________________________________ Date: ________________

* For non‐emancipated minors under the age of 18, a parent or guardian must sign release form. If patient is unable to sign, a copy

of the legal documentation for patient’s representative must be supplied with a copy of this form.

Authorisation To Release Protected Health Information Form

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