Form 1212-0021 - Authorization For Disclosure Of Protected Health Information

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Authorization for Disclosure
of Protected Health Information
Patient Name: _____________________________________________________________________ Date of Birth ________________________________
Full Address: __________________________________________________________________________________________________________________
Phone Number: ________________________________________________________________________________________________________________
Maiden/Previous Names: ________________________________________________________________________________________________________
Instructions: Fill out each section of the form in its entirety. Failure to do so may delay processing of your request.
Release Information From:
Release Information To:
Name/Facility:
Name/Facility:
___________________________________________________________
___________________________________________________________
Address:
Address:
___________________________________________________________
___________________________________________________________
City/State/Zip
City/State/Zip
___________________________________________________________
___________________________________________________________
Phone:
Phone:
_____________________________________________________
_____________________________________________________
Purpose of Release:
Continuing Medical Care
Work Comp
Other: ________________________________________________
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Insurance Claim
Disability Determination
________________________________________________________
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Application for Insurance
Personal
________________________________________________________
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Delivery Method:
Date information desired by: ____________________________________
Release Format (Check 1 of 3 options only):
Mail OR
Pick Up OR
Fax (as appropriate) Fax # : ___________________________________
1.
Paper via
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2.
USB
Mail OR
Pick Up
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3.
Electronic via My Sanford Chart Patient Portal
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Release to ALL My Sanford Chart Proxies
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Information to be Released:
Service Dates: From: ______________________ To: __________________________ OR
all future records until this authorization expires
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NOTE: This authorization expires one year from the date of my signature unless I specify a different event, purpose or
alternative expiration date here: ___________________________________________
Abstract (history & physical, discharge summary, operative reports, consults, outpatient visit notes, test results, labs, ER notes,
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provider notes related to specific timeframe).
Discharge Summary
ER Records
History & Physical
Clinic Visit Notes
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Psychological Evals/Assmts
EKG / Cardiology Reports
Immunization Records
Operative Reports
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Lab / Pathology Reports
Radiology Images
Radiology Reports
Entire Medical Record
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Billing Statements
Other: _______________________________________
(charge may apply)
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Alcohol/Drug Treatment Records ______________________________________________
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I AUTHORIZE RELEASE OF ALL ALCOHOL AND / OR DRUG TREATMENT RECORDS THAT ARE PART OF THE
RECORDS I SPECIFIED ABOVE UNLESS OTHERWISE INDICATED BELOW:
______Do not release alcohol or drug treatment records protected under federal law.
I may revoke this authorization at any time by sending written notice to the facility/provider releasing records. A revocation is not valid
if (1) action was previously taken in reliance on this authorization, or (2) if this authorization was obtained as a condition for obtaining
insurance coverage. I authorize the facility/provider to disclose medical information to the party identified in the “Release Information
To” section. I understand this may include information regarding mental health, alcohol/drug use, and HIV treatment. I understand that
once disclosed, information may be re-disclosed by the recipient and no longer protected. I understand this authorization is voluntary
and that I may refuse to sign. Unless allowed by law, my refusal to sign will not affect my ability to obtain treatment, receive payment,
or my eligibility for benefits.
Signature (required):
Date Signed (required):
Printed Name of Person Signing (If not patient):
1212-0021 Rev. 3/16

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