Form 100-014 - Authorization For Release Of Health Information Form - Renown Health
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1AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION (“Authorization”)
NOTE: ALL sections must be completed
Patient Name: ___________________________________________________________________________ Birth Date: ______________________
Printed (First)
(MI)
(Last Name)
Address: ________________________________________________________________________________ Telephone #: ____________________
Street Address
City
State
Zip Code
I authorize: Renown Health to
(circle one)
SEND TO
-or-
RECEIVE FROM
the below entity:
_______________________________________________________________________ Telephone #: _________________ Fax: ______________
Full Name/Entity
Address: ________________________________________________________________________________________________________________
Street Address
City
State
Zip Code
Purpose of Request to Release:
□ Treatment
□ Personal/Patient Request
□ Legal/Attorney
□ Insurance
□ Other (specify): ________________________________________________________________________________________________________
For Date(s) of Service from: ________________________________ to ____________________________________[Dates MUST be specified]
Information To Be Disclosed:
□ Admission History & Physical
□ Emergency Room Records
□ Consultations
□ Operative Reports
□ Progress Notes
□ Radiology & X-Ray Reports
□ Radiology Films/CDs
□ Laboratory Reports
□ Billing Records
□ Entire Record
□ Other: _______________________________________________
I Specifically Authorize Release of These Records (these records will NOT be released unless you initial & check the box to consent to release):
Initial: _______
□ Release Drug, Alcohol & Substance Abuse Records
Initial: _______
□ Release Communicable Disease Records, including without limitation, HIV/AIDS Records
Initial: _______
□ Release Genetic Testing Records
Initial: _______
□ Release Psychiatric & Mental Health/Behavioral Health Records. Psychotherapy Records will NOT be released.
Release of Psychotherapy Records requires a separate release form. Treating physician approval is required for
release of Psychiatric & Mental Health/Behavioral Health Records.
I UNDERSTAND THAT:
● This Authorization will become effective immediately and will expire on _____________________ [Date]. If no date is specified, this
authorization will expire one (1) year from the signature date.
● I may revoke this Authorization at any time, in a written revocation sent to the Custodian of Records. However, I understand that my health
information might have already been released.
● Information released by this Authorization might be re-disclosed by the recipient and might not be protected by state and federal privacy laws. I
agree to release Renown Health from liability for release and disclosure of the released information.
● I am not required to sign this Authorization as a condition to obtain treatment, services or for eligibility of benefits. My signature on this
Authorization is voluntary.
Signature of PATIENT ONLY: _____________________________________Print Name:______________________________ Date: _____________
Signature of Person Who Is NOT the Patient: _____________________________________________________________ Date: _______________
Print Name: _________________________________________ Authority to Sign: ____________________________________________________
Proof of Authority MUST be attached (except for parents)
Address: ________________________________________________________________________ Tel No: ________________________________
***Completed by Staff Member Fulfilling & Verifying Authorization & Completeness ***
Date: ________________
Time: ___________
Verified By: ______________________________________________________________
MR #: ___________________________________
Account #: ______________________________________________________________
List Document Used to Verify (attach a copy): ____________________________________________________________________________________
Physician Signature for Release of Psychiatric/Mental Health Records: ________________________________________________________________
Printed Physician Name: ____________________________________________________________ Date: ___________________________________
850 Harvard Way
Mail Code B3
□ Tracking only
Reno, NV 89502
□ Mail
Fax: 775-982-3759
□ Patient Pick-up at Harvard Way
Form 100-014
Revised: 11/2017
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Parent category: Business