PATIENT NAME:
DATE OF BIRTH:
MEDICAL RECORD NUMBER:
PHONE #:
RELEASE FROM HOLYOKE MEDICAL CENTER (HMC): I authorize HMC to release my health information to:
Name:
Address:
What to Release:
Dates of Service:
Please include the following information: Entire Record, OR the following (check all that apply)
Abstract (Provider notes, test results)
Operative Reports
Lab results
Pathology Reports
Work Connection (OHS / OHC / EHP)
Radiology Reports (X-Ray, MRI CT) Films
Behavioral Health
Cardiology / EKG Reports
Inpatient
PHP / IOP
Outpatient
Discharge Summary
Other
Purpose of Request: Continuity of Care
Legal
Personal
Other:
RELEASE TO HMC: I authorize
to release my health information to:
Holyoke Medical Center, Attention Dept.
575 Beech St., Holyoke, MA 01040 Fax: 413.534.2651
What to Release:
Dates of Service:
Please include the following information:
Abstract (Provider notes, test results)
Behavioral Health
Discharge/Transfer Summary
Psychosocial Assessment Medication Management Information
Radiology Reports
Films
Treatment Plan/Progress Presence/Progress/Participation Treatment
Operative Reports Laboratory & Pathology Reports Admission & Discharge note for hospitalization (dates)
Other
Other
Purpose of Request: Continuity of Care
Legal
Personal
Other:
RELEASE OF PRIVILEGED INFORMATION:
_____ (Initials) HIV/AIDS: I hereby authorize release of protected health information pertaining to HIV testing and/or diagnosis and/or
treatment related to Acquired Immune Deficiency Syndrome (AIDS) only to the person or organization named above and only for the purpose
name above.
_____ (Initials) GENETIC TESTING: I hereby authorize release of protected health information pertaining to genetic test results only to the
person or organization named above and only for the purpose name above.
_____ (Initials) ALCOHOL and DRUG TREATMENT: I hereby authorize release of treatment records of a licensed drug and alcohol
treatment program to the person or organization named above and only for the purpose name above. I also understand that my Alcohol and
Drug Abuse Records cannot be re-disclosed without my express authorization.
_____ (Initials) INPATIENT PSYCHIATRIC RECORDS OR RECORDS OF A PSYCHOLOGIST OR PSYCHOTHERAPIST: I hereby
authorize release of psychiatric treatment records, and/or records of apsychologist or psychotherapist only to the person or organization
named above and only for the purpose name above.
_____ Domestic violence abuse counselor records
_____ Social service records
_____ Sexual assault counselor records
_____ Sexually transmitted disease records
INDIVIDUAL RIGHTS: I understand the following:
I have the right to revoke this authorization at any time.
If I revoke this authorization I must do so in writing to the attention of the Medical Records Dept, HMC, 575 Beech St., Holyoke, MA
01040, or must contact the party whom I had authorized to release the information, if other than HMC.
My right to revoke does not apply to information already released on the basis of this authorization.
The privacy of my health records is protected under “HIPAA,” 45 CFR, pts 160 & 164, and the privacy of any alcohol and/or drug
treatment records are also protected under the Federal Confidentiality & Drug Abuse Records regulations, 42 CFR, pt 2.
I understand that Holyoke Medical Center cannot guarantee that the Recipient will not re-disclose my health information to anyone else.
There may be a charge for providing copies of medical records.
Expiration Date: This authorization will expire in one year unless revoked or otherwise specified to be the following date, event or
condition:
(person’s initials)
Conclusion of this Treatment Episode
(person’s initials)
Other:
Signature:
Date:
If not signed by person served, specify relationship: Parent
Legal Guardian/Designee
Holyoke Medical Center
AUTHORIZATION TO USE AND DISCLOSE
PROTECTED HEALTH INFORMATION
Permanent Part of the Clinical Record 02/17
MR.HIM.A.1 NEWEST