Authorization To Disclose Health Information Form printable pdf download

Authorization To Disclose Health Information Form

AUTHORIZATION TO DISCLOSE HEALTH INFORMATION

Patient’s Name:

_Phone Number:

______

Social Security Number:

_Date of Birth_

______

Address:

______

City:

State:

Zip Code:

______

I authorize the use or disclosure of the above named individual’s health information as described below:

Release to:

(Name of medical facility, physician, etc.)

(Street Address)

(City, State, Zip code)

The type and amount of information to be used or disclosed is as follows: (include dates where appropriate)

Complete Records

History and Physical Exams

X-Ray, Lab, EKG Reports

Pathology Reports

Developmental Disabilities

Mental Health

Other, specify:

___

I understand I have the right to revoke this authorization at any time. I understand the revocation will not apply to

information that has already been released in response to this authorization. I understand the revocation will not apply to my

insurance company when the law provides my insurer the right to contest a claim under my policy.

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 I may inspect or copy the information to be used or disclosed, as

provided in CFR 164.524. I understand 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 health information management department.

Signature of Patient or Legal Representative

Date

Signed by Legal Representative, Relationship to Patient

Signature of Witness

Authorization To Disclose Health Information Form