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

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

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

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