Authorization Form To Use/disclose Protected Health Information printable pdf download

AUTHORIZATION TO USE/DISCLOSE PROTECTED HEALTH INFORMATION

This authorization must be read, dated and signed by the patient or by a person authorized by law to give authorization on

behalf of the patient.

I, _______________________________________________________________________, born ________________________,

(Patient’s legal name - First, Middle Initial, and Last)

(Patient’s D.O.B. Month/ Day/Year)

hereby authorize Compass Oncology to:

OBTAIN Health Information FROM:

SEND Health Information TO:

______________________________________

_____________________________________________

(Name of sending person/entity)

______________________________________

_____________________________________________

(Clinic / Hospital Name)

______________________________________

_____________________________________________

(Street / Box)

______________________________________

_____________________________________________

(City / State / Zip)

____________________/_________________

______________________/_______________________

(FAX #)

(PHONE #)

(FAX #)

(PHONE #)

By initialing the spaces below, I specifically authorize the release of the following health information:

____ Office chart notes incl. History & Physicals.

____ Radiation Therapy Logs, notes or records.

____ Laboratory reports

____ Consultation Notes.

____ Pathology reports

____ Diagnostic imaging reports and Films

____ Medication Flow sheets inc. known Allergies.

____ Billing and accounting statements.

____ Other_______________________________________________________________________________________

I understand that federal or state laws may restrict disclosure of HIV/AIDS information, mental health information, genetic testing

information, and drug/alcohol diagnosis, treatment or referral information. By initialing the spaces below, I specifically authorize the

release of the following health information:

____ HIV/AIDS related records including HIV testing

____ MENTAL HEALTH information

____ DRUG/ALCOHOL diagnosis, treatment or referral information

____ GENETIC TESTING information (which may include testing to determine the characteristics of tumor)

I understand that my health information may be re-disclosed by the person or entity receiving my health information from

Compass Oncology and that it may no longer be protected under federal or state laws.

I understand that the health information will be used for_____________________________________________________________.

(List stated purpose - be specific)

I voluntarily sign this authorization and I understand that my ability to obtain health care from Compass Oncology will not be affected if I

refuse to sign this authorization.

This authorization expires on: _____________________________________________________________

________________

(Please specify the date or an event that triggers the expiration)

(event)

(exp date)

I understand that I may revoke this authorization at any time by notifying Compass Oncology in writing, and that my

revocation is not effective to the extent that NCS has acted in reliance on this authorization. This authorization will expire 180

days from the date of signing or on the expiration date or event specified, if earlier.

______________________________________________________________

___________________________________

Signature of Patient or Person Authorized by Law to Act on Patient’s behalf

Today’s Date

If this authorization is signed by a person authorized by law to act on behalf of a patient, please describe your relationship to the

patient: ____________________________________________________________________________________________________________

Authorization Form To Use/disclose Protected Health Information

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