Medical Records Release-Authorization To Use And Disclose Health Information Form 2011
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1Updated 8/31/2011
Medical Park Family Care, Inc.
2211 E. Northern Lights Blvd., Anchorage, AK 99508
(907)279-8486 Fax (907)257-8192
Authorization to Use and Disclose Health Information
Patient Name (Please Print) _____________________________Phone#____________
Date of Birth ________ Other Names ________________SS# ____________(optional)
I am the ______ Patient ______ Guardian ______ Other (Please name______________)
I authorize Medical Park Family Care
I authorize Medical Park Family Care
to request my health information as
to release my health information as
identified below from:
identified below to:
(
(
Physician name, address & phone/fax #)
Physician name, address & phone/fax #)
__________________________________
_________________________________
__________________________________
__________________________________
__________________________________
__________________________________
(Circle one) PAPER COPY
CD/DIGITAL COPY
(Circle one) MAIL
FAX
PICK-UP
Purpose of disclosure:_____________________________________________________
I specifically authorize the use or disclosure of the following health information:
____ ALL MEDICAL RECORDS
____ Radiology Reports ____ Radiology Films from ____ to ____
____ Chart Notes ALL or from ______ to ______
____ Labs ALL or from ______ to ______
____ Billing Statements
____ Other (please list)____________________________________________________
*The following items must be initialed to be included in the use or disclosure of other health
information:
____*HIV/AIDS related health information and/or records
____*Mental health information and/or records
____*Drug/alcohol diagnosis, treatment, and/or referral information
(Federal Regulations require a
description of how much & what kind of information is to be disclosed. Federal law prohibits the re-disclosure of such information).
Unless revoked earlier, this authorization will expire 180 days from the date of signing
or upon (insert date or event of expiration) ___________________________.
Except to the extent that action has already been taken in reliance upon the authorization , I understand that I may revoke this
authorization at any given time by giving written notice.
I understand that, if the person or entity receiving this information is not a health care provider or health plan covered by federal
privacy regulations, the information described above may be re-disclosed and no longer protected by these regulations.
Please allow 10 working days for processing.
______________________________________________
_________________
Signature of Patient or Patient’s Legal Representative
Date
__________________________________
_____________________________
Print name of legal representative (if applicable)
Relationship of Legal Representative to Patient
Picture ID #________________Released By (Employee Initials)______ Prepared By (Employee Initials) ______
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