Authorization To Disclose Protected Health Information Form

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Authorization to Disclose Protected Health Information
The undersigned authorizes
University Orthopaedic Clinic, PC
305/400 Bryant Drive East ● Tuscaloosa, AL 35401
Ph. 205-345-0192 ● Fx. 205-345-7341
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: _________________________________________
(Please ensure email address is legible.)
Personal
Treatment
Legal
Insurance
Transfer
Other:____________
Purpose of Request:
Mail
Fax (for Dr’s Offices)
Email (For Patients)
Please forward Records by:
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 AL Statute Section 12-21-6.1
Please release a 2 year abstract of my records
Search fee: $5.00 per request
Please release my entire record.
Copy fee: $1.00 per page for pages 1-25 / $0.50 per
Other (please specify): ____________________________
page, thereafter / Postage, if applicable
______________________________________________
Records being sent to another healthcare provider will be
Radiology Disk (*$25 fee for disk)
provided at no cost*.
There is a $25 fee for Radiology Disks.
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 19, 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.

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