Authorization For Disclosure Of Health Information

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AUTHORIZATION FOR DISCLOSURE OF HEALTH INFORMATION
(1) I hereby authorize (name of provider) ______________________________________________________________
(2) To disclose the following information from the health records of:
Patient name: _____________________________________________ Date of birth: _______________________
Address: ____________________________________________ Telephone:_____________________________
____________________________________________
Medical Record Number: _________________
Dates of Admissions:__________________________________________________________________________
(3) Information to be disclosed:
□
□
Complete health record(s)
Discharge summary
□
□
History & physical examination
Progress notes
□
□
Consultation reports
Laboratory tests
□
X-ray
Other (please specify) _____________________________________________________________________
I und erstand that this will include information relating to (check if applicable)
□
Acquired immunodeficiency syndrome (AIDS) or human immunodeficiency virus (HIV) infection.
□
Behavioral health services/psychiatric care.
□
Treatment for alcohol and/or drug abuse.
Initials_____________
(4) At the request of the patient, this information is to be released to: ________________________________________
________________________________________
________________________________________
for the purpose of _____________________________________________________________________________
(5) I understand this authorization may be revoked in writing at any time, except to the extent that action has been
taken in reliance on this authorization. Unless otherwise revoked, this authorization will expire 12 months from the
date signed. I also understand I may refuse to sign this form and that my health care and payment
will not be affected.
Initials_____________
(6) The facility, its employees, officers, and physicians are hereby released from any legal responsibility or liability for
disclosure of the above information to the extent indicated and authorized herein.
Initials_____________
(7) I may request a copy of this form after signing.
Signed:
______________________________________________________________ Date:_____________
(Patient)
(This form has been
completed before signing)
________________________________________________________________________ Date: _____________
(Relationship to patient,
(Legal representative)
description of authority)
________________________________________________________________________ Date: _____________
(Signature of witness)
(Relationship to patient)
SPANISH VERSION: MR2N286ST
MR2N012 (11/03)
Note: Release of all confidential information is g overned by State and Federal and HIPAA Regulations

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