Authorization For Use Or Disclosure Of Protected Health Information

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AUTHORIZATION FOR USE OR DISCLOSURE
OF PROTECTED HEALTH INFORMATION
Please print clearly.
Patient Name: _________________________________________________
Phone #: (_______) ______________________
Other Names Used: _______________________________________________________________________________________
Patient Address: _______________________________________________
Date of Birth: ____________________________
____________________________________________________________
Social Security #: ________________________
____________________________________________________________
Medical Record #: ________________________
Saint Mary’s Facility: ____________________________________________
Completion of this document authorizes the disclosure and/or use of health information about you. Failure to provide all information
requested may invalidate this authorization.
I AUTHORIZE: _______________________________________________________________________________________
(Facility or other provider)
TO DISCLOSE TO: ____________________________________________________________________________________
(Persons / organizations authorized to receive the information)
at the following address: ________________________________________________________________________________
(Street address)
___________________________________________________________________________________________________
(City, state and zip code)
the following information (check box and initial applicable lines below):
_____ Mental health (excludes “psychotherapy notes”)
£
_____ Substance abuse treatment records
£
_____ Genetic testing information
£
£
THE FOLLOWING RECORDS, specific types of health information, or records for the date(s) of treatment as
specified [check applicable box(es)]:
Billing Records
Emergency Room
Procedure Reports
£
£
£
£
Consultation Reports
£
History and Physical
£
Progress Notes
£
Discharge Summary
£
Laboratory Tests
£
X-ray Reports
£
Imaging
£
Date(s): _____________________________________________________________________________________
£
Other(s): _____________________________________________________________________________________
ALL RECORDS regarding my treatment, hospitalization, and outpatient care.
£
A separate authorization is required for the use or disclosure of psychotherapy notes or research health information.
PLEASE CONTINUE ON NEXT PAGE
PATIENT ID
*2 HIMROI*
2 HIMROI
AUTHORIZATION FOR USE OR DISCLOSURE OF
PROTECTED HEALTH INFORMATION
PHSI- 280-014- SMR MC (0 7 /12)
ORIGINAL - CHART
COPY - PATIENT
PAGE 1 OF 2

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