Authorization To Use Or Disclose Health Care Information Form

Authorization to Use or Disclose Health Care Information

Health Information Management Department, 9621 Ridgetop Blvd NW, Silverdale, WA 98383

Phone: (360) 782-3724 Fax: (360) 782-3797

TDC contracts with IOD Incorporated a national healthcare information release company

I Hereby Authorize The Doctors Clinic:

or:

Facility / Doctor’s Name: _______________________________________________________________________________

Address: __________________________________________________________________________________

City: ________________________________________ State: _________ Zip: _________________________

Phone: _______________________________________ Fax: _____________________________________

To Release: (Please check all that apply)

___Last two years of Chart Records

(does not include billing information or radiographic images)

___Specific: Chart Notes: _______________________________Labs/Reports: __________________________________

Billing Records: ___________________________ Other:_________________________________________

Radiographic Studies:_________________________________________________REPORT__Image CD__

Only the last two years of medical records originated through this healthcare facility will be provided.

From The Health Records Of:

Name: _________________________________________________Date of Birth: _________________________________

Social Security Number: _______________________Daytime Phone: ____________________________________________

⁭

Are you authorizing the release of your own records?

___Yes ___ No

If not, what is your name and relationship to the patient?

Name: ________________________________________________

Relationship: ______________________________

Release of certain medical information requires minor’s consent. This applies to persons age 13 to 17 for information pertaining to

substance abuse and mental health information, or persons age 14 to 17 for information pertaining to sexually transmitted diseases, HIV

and AIDS. Other laws may apply.

To Be Released To:

___ Self (please indicate mailing address below) On or By: ___Paper ___Fax ___Electronically

___Facility / Doctor’s Name: ____________________________Appointment Date and Time_______________________

Address: ______________________________________________________________________________________

City: _____________________________________________

State: ______ Zip: ________________________

Phone: __________________________________________

Fax: _____________________________________

___ Other than self. Name of person________________________________________________ Relationship:__________

For The Purpose Of: (Please check all that apply)

Concurrent/Referral Care ___ Transfer of Care ___ At My Request ⁭ Other: _________________________________

___



I understand if I request my records for personal use, and the request exceeds 10 pages I will be charged by the The Doctors

Clinic contracted release service (IOD) thirty nine cents per page for page 11and greater prior to receiving my records,

My Rights:



I understand that unless revoked, this authorization is valid for 90 days from the date of signing. I understand that I may revoke

this authorization in writing at any time except to the extent disclosure has already been made in accordance with this document.



I understand that I do not have to sign an authorization as a condition for receiving treatment or health care benefits (treatment,

payment or enrollment).



Unless specifically excluded, this authorization includes release of specially protected information requiring my explicit

authorization for release. This includes referral, diagnosis and treatment information related to: (Please check or circle all that

apply to EXCLUDE the information from authorization):

⁭ Substance Abuse

⁭ Mental Health Conditions

⁭ Sexually Transmitted Diseases ⁭ HIV/AIDS



I understand once The Doctors Clinic has released my health care information to the above named entity, the person or

organization that receives it may re-disclose the information and that it may no longer be protected by privacy laws.



I understand release of my records may take up to 15 working days.

I have read the above Authorization to Release Information and do hereby acknowledge that I am familiar with and fully understand the

terms and conditions of this authorization.

Patient Signature: ________________________________________________________Date:________________________

POA/ Patient Guardian Signature:___________________________________________Date:_______________________

Please attach a copy of legal documents if you are the legal guardian or holder of Power of Attorney or indicate they are on

file in the patients chart.

Authorization To Use Or Disclose Health Care Information Form - Washington

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