Chkd Form 0764 - Authorization To Use Or Disclose Protected Health Information

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Children's Hospital of The King's Daughters Health System
MR #:
601 Children's Lane, Norfolk, VA 23507-1910
Authorization To Use Or Disclose Protected Health Information
PATIENT NAME:
DATE OF BIRTH:
I AUTHORIZE: Children's Hospital of The King's Daughters Health System, Inc.(CHKDHS)
601 Children's Lane, Norfolk, VA 23507-1910
TO DISCLOSE: (description of the health information on the patient identified above that is to be disclosed)
[ ] the shot/immunization records
[ ] any and all of the medical records pertaining to the treatment of the patient seen in the
hospital or clinic on or about _____________________________ 20_______.
[ ] specify:_____________________________________________________________________________
___________________________________________________________________________________
TO:
Name/Institution:________________________________________________________________________________
Address:_______________________________________________________________________________________
City/State, Zip: __________________________________________________________________________________
Fax Number:____________________________________________________________________________________
FOR THE FOLLOWING PURPOSE:
[ ] At the request of the individual [ ] Other (specify): _______________________
______________________________________________________________________________________________________
NOTE: The purpose is not required if the disclosure is requested by the patient unless the disclosure concerns substance abuse information under the
Federal Substance Abuse Confidentiality Requirements.
I understand that any disclosure of health information carries with it the potential for an unauthorized re-disclosure and the
information may not be protected by federal privacy rules.
(NOTE: The recipient may be prohibited from disclosing substance abuse
information under the Federal Substance Abuse Confidentiality Requirements.)
I understand that I may revoke this authorization at any time except to the extent action has been taken in response to this
authorization. I also understand that the revocation will not apply to my insurance company when the law provides my insurer
with the right to contest a claim under my policy. I understand that if I revoke this authorization I must do so in writing and
present my written revocation to Health Information Management, Children's Hospital of The King's Daughters, 601 Children's
Lane, Norfolk, VA 23507-1910. (
The written revocation must be legible and include the name and date of birth of the patient, the date the revocation
is to go into effect, a description of the health information covered by the revocation, the person/entity no longer authorized to the receive the information, the
signature of the person with legal authority for authorization/revocation, and if not the patient, a description of their legal authority for
authorization/revocation, and their phone number.)
Unless otherwise revoked, this authorization will expire on the following date, event, or condition:_______________________
____________________________________. If I fail to specify an expiration date, event, or condition, this authorization will
expire in one (1) year.
Required if request is for the purpose of Marketing:
1. I understand that CHKDHS [ ] will
[ ] will NOT
receive payment as a result of using/disclosing this information.
Required if patient/legal guardian is NOT requesting or CHKDHS IS requesting the disclosure: (check only when applicable)
1. I understand that I may refuse to sign this authorization and that, in this instance,
[ ] my refusal to sign will not affect my ability to obtain treatment, payment, or my eligibility for benefits.
[ ] the law allows conditioning of treatment, payment, or my eligibility for benefits on this authorization, and the
consequence of my refusal to authorize this disclosure is ________________________________________________
______________________________________________________________________________________________
2. CHKDHS IS REQUIRED TO GIVE PATIENT/LEGAL GUARDIAN A COPY OF THIS AUTHORIZATION.
I certify that I am the patient, the patient’s parent or legal guardian with the authority to authorize disclosure of this patient’s
protected health information.
________________________________________________________
____________________
SIGNATURE OF PATIENT/LEGAL GUARDIAN
DATE
________________________________________________________
RELATIONSHIP TO PATIENT/LEGAL AUTHORITY
CHKD Form 0764 Rev 4/10
FAX TO CHKD HIM (Medical Records) DEPT. 757 668-7625 or MAIL TO ADDRESS ABOVE

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