Authorization To Release Medical Information printable pdf download

Post Falls Family Medicine, PA

Christopher Billingslea, D.O.

Morgan Ford, M.D.

Anthony Peters, D.O

Michael Monohan, D.O.

Shauna Spellman, ARNP

Annalee Wilson, ARNP

Chelsey O’Neill, ARNP

Authorization to Release Medical Information

Patient Name (Please Print):__________________________________________________________________________

Patient’s Date of Birth: _____________________________________ Patient Phone: __________________________

RELEASE/SEND RECORDS TO:

__________________________________________________________________________________________________

Phone: _________________________________________Fax:_______________________________________________

Information to be released:

____ The most recent 2 Year’s pertinent information (chart notes, labs and tests)

____ All medical information

____ Other Information (Please specify) _______________________________________________________________

Purpose for which disclosure is being made: (please check one of the following)

____ Attorney _____ Insurance _____ Doctor _____ Personal _____ Other _________________________________

EXCLUDE the following information from the records released (please initial):

____ Drug/Alcohol abuse/treatment and diagnosis

_____ Sexually transmitted disease

____ Mental Illness or psychiatric diagnosis and treatment

_____ HIV/AIDS

MY RIGHTS:

I understand that if the person or entity that receives the 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

the HIPAA regulations. However, the recipient may be prohibited from disclosing substance abuse information under

the Federal Substance Abuse Confidentiality Requirements.

I understand I may refuse to sign this authorization and that my refusal to sign will not affect my ability to obtain

treatment or payment or my eligibility for benefits. I may inspect or obtain a copy of any information used/disclosed

with this authorization. There may be a charge for these copies.

This authorization will automatically expire six months from the date signed or until the 3rd party payer claim is

secured. I understand that I may revoke this authorization any time except to the extent that action has been taking in

relationship thereon. To revoke this authorization I must submit my request in writing to Post Falls Family Medicine,

P.A.

Signed: ____________________________________________________ Date: __________________________

(Patient, Guardian*, or authorized representative*)

*Please provide documents to prove authority to sign on behalf of the patient.

Possible copying fee required

Authorization To Release Medical Information