Form Cc 461 - Authorization To Release Medical Records

ADVERTISEMENT

*** For Office Use Only ***
Log #: _________________ MR#: ____________________
ID verified? Y
N
By (initial): _______________
Beverly Hospital
Lahey Outpatient Center, Danvers
Addison Gilbert Hospital
Hunt Center
BayRidge Hospital
Authorization to Release Medical Records
Patient Information
** Please Print **
Patient Full Name: __________________________________________ Date of Birth: __________________________
Patient Address ____________________________________________ Phone: ______________________________
City: ______________________ State: ________ Zip: _____________
Work Phone: _________________________
Release/Send Information To
I hereby authorize:
Beverly Hospital
Addison Gilbert Hospita
BayRidge Hospital
LOC, Danvers
Hunt Center
l
Or
___________________________________ to release information contained in my medical record to:
Other Facility:
Name/Facility: ______________________________________________ Attention: ____________________________
Address: __________________________________________________ Phone: ______________________________
City: ______________________ State: ________ Zip: _____________
Fax #: _______________________________
Mail
Pick up (date) ______________
Email to ________________________________
Fax to above #
Information to Release/Send
Comments / Dates / Notes
Please provide an abstract: History/physical, Summary, Consult,
Op Note, Intake, Labs, Radiology, EKGs, ER report
Please provide a copy of my emergency department record
Other – please be specific, including dates, MDs, tests (fill in box)→
Purpose of Request:
Personal
Continuing Care
Insurance
Legal
Other: _________________________________________
.
Authorization to Release/Send Protected or Sensitive Information
In order for us to release any of your medical information that may fall into the categories listed below, you must initial
on the line. We will not send out this information if the line is blank
WRITE YOUR INITIALS ON THE LINE
I authorize psychiatric/psychological treatment notes to be released
___________________
I authorize information about drug &/or alcohol substance abuse/treatment to be released __________
________
I authorize information about sexually transmitted disease to be released
___________________
I authorize information about HIV/AIDS testing &/or treatment to be released
___________________
Please make sure you have filled out this form completely: printing your full name and date of birth, checking the
purpose of the request, checking the information to be released, and initialing ALL the protected/sensitive
information categories above that may pertain to your records.
I understand that authorizing the disclosure of this health information is voluntary. I need not sign this form in order to assure treatment. I understand
that I may inspect or copy the information to be used or disclosed, as provided in CFR 164.524. I understand that any disclosure of information
carries with it the potential for an unauthorized re-disclosure and the information may not be protected by federal confidentiality rules. If I have
questions about disclosure of my health information, I can contact the Privacy Officer or Director of Health Information.
I understand that I have a right to revoke this authorization; I must do so in writing and present my written revocation to the Medical Records/Health
Information Management Department. I understand that the revocation will not apply to information that has already been released in response to this
authorization. I 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. 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 90 days from the date of signing.
_______________________________________ ___________ ___________________________
Signature - Attach legal documents when applicable
Date / Time
Relationship, if other than patient
Please note: There may be a charge for the copying and mailing of medical record copies.
Rev: 4/17/03, 11/18/04, 3/30/05, 12/05, 06/10, 6/13 Form # CC 461 Macintosh HD:Users:jamie:Downloads:461 authorization to release medical records 6.2013.doc

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Business
Go