Fillable Health Information Release Form - Callen Lorde printable pdf download

HEALTH INFORMATION RELEASE FORM

Section 1: Patient Information

Last name:

First Name:

Today’s date:

Address:

Apartment #:

Date of Birth:

Phone number:

City:

State:

Zip Code:

(

)

Section 2: Release Information To

I hereby authorize Callen-Lorde Community Health Center to share my individually identifiable health information, which may include

protected or privileged information form to the below listed person/organization.

Name:

Organization and Department:

Address:

Phone number:

(

)

Fax number:

City:

State:

Zip Code:

(

)

Section 3: Information to be Disclosed

Fax

Mail

Pick-up

Verbal/3rd party communication

Please check how the information should be initially released:

Dental Records: Please check Yes or No type of

Medical Records: Please check Yes or No for each of the following types of records:

record to be released and from which time period:

Yes

My records for medical treatment during the following

________________ to ________________ .

Yes

time period ________________ to ________________ .

Dental - Radiographs

Most recent laboratory results

Dental - Treatment Plan

All laboratory results

Dental - Progress Notes

All medical records

All dental records

Other records: _____________________________________________________

Other: _____________________________

Release is to exclude the following information: __________________________________________________________________________

Section 4: Sensitive Information

The following categories of information will NOT be released from your records without your specific authorization. To authorize release,

sign your complete name next to the categories you want released.

Information to be Disclosed

Patient Signature

HIV Related Information

(Including HIV Testing)

Mental Health Treatment

Substance Use & Treatment

(Including alcohol/drug)

Section 5: Release Reason & Time Frame

Time Frame:

Reason: I authorize release of information for the following reason:

Please specify the date of expiration if different

than 12 months.

I, or my authorized representative, request that health information regarding my care and treatment be released as set forth on this form. I understand that:

This authorization may include disclosure of information relating to ALCOHOL and DRUG TREATMENT, MENTAL HEALTH TREATMENT, and CONFIDENTIAL HIV/AIDS RELATED

INFORMATION only if I place my signature on the appropriate line section 4 of this form. In the event the health information described above includes any of these types of

information, and I signed the line in the Sensitive Information section, I specifically authorize release of such information to the person(s) indicated in section 2.

With some exceptions, health information once disclosed may be redisclosed by the recipient. If I am authorizing the release of HIV/AIDSrelated, alcohol or drug treatment, or mental

health treatment information, the recipient is prohibited from redisclosing such information or using the disclosed information for any other purpose without my authorization unless

permitted to do so under federal or state law. If I experience discrimination because of the release or disclosure of HIV/AIDSrelated information, I may contact the New York State

Division of Human Rights at 18883923644. This agency is responsible for protecting my rights.

I have the right to revoke this authorization at any time by writing to Callen-Lorde Community Health Center. I understand that I may revoke this authorization except to the extent

that action has already been taken based on this authorization.

Signing this authorization is voluntary. I understand that generally my treatment, payment, enrollment in a health plan, or eligibility for benefits will not be conditional upon my

authorization of this disclosure. However, I do understand that I may be denied treatment in some circumstances if I do not sign this consent.

For Staff Use Only:

Processed:

Date: _____________

By: _________________________

Patient Signature

Date

*This authorization expires 12 months from the date it was signed unless

Sent via: _____________________

Staff Witness: _______________

otherwise specified in Section 5.*