Authorization To Release Protected Health Information

ADVERTISEMENT

Health Information Management Department
4098 Libra Drive, Orlando, FL 32816-3333
Tel (407) 823-2091, Fax (407) 823-3359
Authorization to Release Protected Health Information
Entire Medical Record:  All /  Specific date: _____________
GYN Records:  All /  Specific date: ________________
Dental Record/Images:  All /  Specific date: ______________
Lab Result: List test(s) or date(s): ______________________
Radiologist Interpretation/Report:_______________________
Copy of Medical Images: ____________________________
Immunization Records:  All or  Specific Immunization ___________________________________________________________
Other: ________________________________________________________________________________________________________
I understand that this information may include HIV-related information and/or information relating to diagnosis or treatment of psychiatric
disabilities and/or substance abuse and that by initialing below, I am specifically authorizing the release of information relating to:
____ Alcohol Abuse
____ Sexual Assault Records
____ Drug Abuse
____ STD
____ HIV and/or AIDS
____ Psychiatric Records
The confidentiality of this record is required under U.S. Public Law 104 and Florida State Law. This material shall not be transmitted to anyone without written
consent or authorization as provided in these statues.
 Pick up
 Mail
 Fax
 Consent to Discuss
Format:
 Paper
 CD
 Flash Drive
 Email
Entity Releasing Information
Entity Receiving Information
Name: ___________________________________________
Name: __________________________________________
Address: _________________________________________
Address: ________________________________________
Phone: _______________________ Fax________________
Phone: ________________ Fax: _____________________
Email Address:___________________________________
Purpose of Disclosure: Continuity of Care _____ Other_____________________________________________________
I understand if the requester or receiver is not a health plan or health care provider, the released information may no longer be protected by
federal privacy laws and may be redisclosed.
I understand that I may ask and get a copy of this authorization after I sign it.
UCF Student Health Services may not deny treatment, payment, enrollment or eligibility for benefits based on whether or not I sign this
authorization.
I understand that this authorization will expire 90 days from date signed unless another date is specified for continuous exchange
of information. Expiration Date: _____________
I understand that I may revoke this authorization at any time by notifying the providing organization in writing, but if I do, it won’t have
any affect on any actions UCF Student Health Services took before they received the revocation.
******IF NOT SIGNED IN PERSON FORM MUST BE NOTARIZED BELOW IN THE WITNESS SECTION******
Patient Signature: _____________________________________
Date: ____________________________
Print Name: _______________________________
Date of Birth: __________
UCF ID# _________________________
____________________________________________
_________________________________
Signature of Parent or legal Guardian (when applicable)
Date
___________________________________________
_________________________________
Witness Name & Signature
Date
Revocation of Authorization
I, __________________________________________________, would like to revoke this authorization as of: ________________
Signature to Cancel: __________________________________
*****CONFIDENTIALITY NOTICE*****
The documents accompanying this telecopy transmission contain confidential information belonging to the sender that is legally privileged. This information is intended only for the use
of the individual or entity named above. If you are not the intended recipient, you are hereby notified that any disclosure, copying, distribution, or action taken in reliance on the
contents of these documents is strictly prohibited. If you received this telecopy in error, please notify the sender immediately to arrange for return of these documents.
Emailed By: _______
Faxed By: ___________
Mailed By: ___________
Hand Carried By: ___________
Date: ___________
Revised: 06/09/2015

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Medical
Go