Authorization For Release Of Protected Health Information Form printable pdf download

MEDICAL RECORDS

2720 Sunset Blvd., West Columbia SC 29169 • (803) 791-2264 • FAX: (803) 791-2136

Authorization for Release of Protected Health Information

Patient’s full name at the time of treatment:___________________________________________________________________________________

Date of Birth:________ / ________ / _____________

Social Security Number: ____ ____ ____ – ____ ____ – ____ ____ ____ ____

Date(s) of treatment: ____________________________________________________________________________________________________

Purpose of release: _____________________________________________________________________________________________________

I authorize the following provider/entity __________________________________________________________________ to release my health information to:

Recipient/Provider Name: _________________________________________________________________________________________________________

Recipient’s Address: _____________________________________________________________________________________________________________

City: _____________________________________________________________ State: _______________________________ ZIP: __________________

Portal

Mail Record

Pick-up

FAX (to health provider only)

I request a copy of this authorization

Information To Be Released:

(Please check all that apply)

Bill

Pathology Reports

Cytology Reports

Physical Therapy Reports

Diagnosis List/Patient Identification

Physician Dictation (type) _________________________________

Emergency Department Records

Pulmonary Function Test

EKG/Cardiovascular

Radiology Film (type) _____________________________________

Laboratory Report (type) __________________________________

Radiology Reports

Mammography Films

Speech Therapy Reports

Occupational Therapy Reports

Other: ________________________________________________

Office Notes (type) ______________________________________

________________________________________________________

1. I understand that if my records contain documentation of alcohol abuse, psychiatric condition, drug abuse, or communicable diseases, this information will be released

as part of my record.

2. I understand that if the person or entity receiving this information is not covered by federal privacy regulations, this information will no longer be protected and may

be re-disclosed.

3. I understand that I may revoke this authorization at any time, but revocation will not apply to information that has already been released. Revocations should be sent

to the address noted at the top of the form.

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

5. I understand that there may be a charge for obtaining the requested information. Information on the charge can be obtained by contacting the medical records

department noted at the top of this form.

6. I understand that a copy or FAX of this document is just as valid as the original document.

7. I understand that this authorization will expire 90 days after signed unless an earlier date is specified here _____________________________________________.

_____________________________________________________________

___________________________

______________________________________________

Signature of Patient or Authorized Person

Date

Contact Telephone Number

_______________________________________

____________________________________________________________________________________________________

Relationship

Reason Patient is Unable to Sign

Original to Medical Records:___________ / ___________ / _____________

Copy to: ___________ / ___________ / _____________