Patient Authorization For Release Of Medical Information To Third Party Form
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1
2PATIENT AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION TO THIRD PARTY
Patient’s Name:
________________________________________________________________________________
(Last)
(First)
(Middle)
Date of
Unit Number: ________________
Birth: __________________
Tel. No.:___/_____/___________
Month/Day/Year
Address: ____________________________________________________________________________________
(Street)
(City)
(State)
(Zip Code)
Please request/check all that apply:
I authorize Mount Sinai to disclose medical information about my:
Manhattan
Queens
Huntington
___Emergency Room visit on: __________________________________________________
Date(s)
___OPD Clinic visit, specify clinic: _______________________________________________
Date(s)
___FPA Practice/Provider_______________________________________________________
Name of Provider
Date(s)
___ Hospitalization from: __________________________ to __________________________
Admission Date(s)
Discharge Date(s)
___ Ambulatory Surgery:
Date: ________________________
____Specify (i.e. Lab tests, Operative Reports)______________________________ Date____________
Records to be disclosed ____ do include ____ do not include HIV-related information.
____ do include ____ do not include Alcohol and Drug Abuse records.
____ do include ____ do not include Psychiatric Records.
x
To
Healthcare Provider
Insurance Company or Designee
Attorney
Court
Law Enforcement
Employer
Other: _______________________________________________________________________
Name: _____________________________________________________________________________
Address: ___________________________________________________________________________
WTC VICTIMS COMP FUND CLAIM
X
Reason for Disclosure
Patient Request
Other: ____________________________________
We will not condition treatment or payment on whether you sign this authorization. However, if you refuse to sign
we will not release your records.
1 – Medical Record Copy
2- Patient Copy
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Parent category: Legal