I understand that this authorization is valid only for a maximum of 90 days from the date below, and it covers
only treatment prior to the date below.
This information may be released by facsimile machine if request warrants. Commonwealth Health
Corporation and its subsidiaries are hereby released from any liability and the undersigned will hold
Commonwealth Health Corporation harmless for complying with this authorization. A photostat copy of this
authorization is acceptable and will be treated as original.
The undersigned acknowledges that the provision of free medical records by any healthcare provider who
receives this release shall fulfill that healthcare provider’s obligation to provide one free copy of the medical
records, and that any future report request for medical records from the healthcare provider may result in a
copying fee up to one dollar per page.
I understand that the information in my health record may include information relating to sexually transmitted
disease, acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV). It may also
include information about behavioral or mental health services, and treatment for alcohol and drug abuse.
I understand that I have a right to revoke this authorization at anytime. I understand that if I revoke this
authorization I must do so in writing and present my written revocation to the 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.
Revocation date__________________ Patient/Legal Representative:______________________________
I understand that authorizing the disclosure of this health information is voluntary. I can refuse to sign this
authorization. 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 comes with it the potential for an unauthorized redisclosure 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 Health Information Management Department.
Patient/Legal Representative Signature: ____________________________________ Date:_____________
Relationship to patient:__________________________________
Please mail the completed authorization form to:
Attn: Release of Information
Health Information Management Department
The Medical Center
250 Park Street
Bowling Green, KY 42101
FOR OFFICE USE ONLY
Released by: ____________________________________
# of pages copied: ______________
First free copy: Yes
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