Authorization For Use Or Disclosure Of Protected Health Information Page 2

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PURPOSE: The purpose and limitations (if any) of the requested use or disclosure is:
At the request of the patient or personal representative; OR
£
Other: _______________________________________________________________________________________
£
EXPIRATION: This authorization will automatically expire one (1) year from the date of execution unless a different event or
end date is specified: __________________________________________________________________________________
(Insert date or event)
MY RIGHTS:
I may refuse to sign this authorization. My refusal will not affect my ability to obtain treatment or payment or eligibility for
∑
benefits.
I may revoke this authorization at any time, but I must do so in writing and submit it to the following address:
∑
Saint Mary’s, 235 West Sixth Street, Reno, Nevada 89503, Department: Health Information Dept., Release of Information.
My revocation will take effect upon receipt, except to the extent that others have acted in reliance upon this authorization.
Information disclosed pursuant to this authorization could be re-disclosed by the recipient. Such re-disclosure may no longer be
protected by federal confidentiality law (HIPAA). If this authorization is for the disclosure of substance abuse information, the
recipient may be prohibited from disclosing the information under 42 C.F.R. part 2.
SIGNATURE: ________________________________________________
Date: ______________________________
(Patient or personal representative)
_______________________________________________
_______________________________________________
Print name of personal representative
Relationship to patient
Patient / Representative Identification Verified.
Initials: _____________
Dept: ______________________________
Note: If the substance abuse treatment information is protected by federal confidentiality rules (42 C.F.R. part 2) the following
prohibition of re-disclosure statements must be provided to the recipient of the information:
The federal rules prohibit the recipient from making any further disclosure of the information unless further disclosure
is expressly permitted by the written consent of the person to whom it pertains, or as otherwise permitted by 42 C.F.R.
part 2. A general authorization for the release of medical or other information is NOT sufficient for this purpose. The
federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse patient.
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 2 OF 2

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