Authorization To Use And Disclose Health Information Form printable pdf download

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

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

Authorization To Use And Disclose Health Information Form

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