Authorization Form For Release Of Information

ADVERTISEMENT

IHA Office: ____________________________ Authorization for Release of Information
I AUTHORIZE AND REQUEST (list who this request is addressed to here):
_______________________________________________________________________________________________________
PATIENT NAME:________________________________/_____________________/_____________/_______________________
Last Four SS#
LAST
FIRST
MI
MAIDEN OR OTHER NAME
DATE OF BIRTH
AUTHORIZED BY: (Patient, Parent or legal guardian); and I am authorized to make this disclosure:
Name:
_______________________________________ Date of Birth: ___________ Last Four SS #: __________Phone# ________________
Address: ________________________________________City____________________________ State____________ Zip Code:___________
RELEASE TO:
NAME: _____________________________________________ ADDRESS: __________________________________________
CITY: _________________________ STATE: _____________ ZIP: __________
INFORMATION TO BE RELEASED:
Specifically any and all of the medical record information in your possession as well as any other employee, provider, nurse,
nurse practitioner or any other person employed by IHA and involved in my health care;
Any records of medications, problem lists, tests, procedures or referrals ordered;
Any records from any outside medical health providers, in-patient or out-patient that are part of my health record that are in the possession
of IHA.
This authorization specifically includes my entire medical record including, Substance abuse, Mental Health, HIV related testing
and treatments.
Other: _____________________________________________________________________________________________
PURPOSE OF DISCLOSURE:
 Relocating out of area  Changing doctor in area
 Specialist Consultation/second opinion  Transfer from pediatric to adult doctor Legal  School
 Insurance Change (Non-par)
 Workers Compensation  Doctor’s Care  Nursing Staff  Other Staff Other
60
1. I understand that this authorization will expire on _________________ (Print the Date this form Expires) OR,
days after I have signed the
form.
2. I understand that I may revoke this authorization at any time by notifying the providing organization in writing, and it will be effective on the
date notified except to the extent action has already been taken in reliance upon it. I understand that information used or disclosed pursuant
to this authorization may be subject to re-disclosure by the recipient and no longer be protected by Federal privacy regulations.
3. By authorizing this release of information, my health care and payment for my health care will not be affected if I do not sign.
4. I understand that in compliance with the State of Michigan laws pertaining to record copies, I may be charged a reasonable cost based fee
no greater than $________. There is no charge for medical records if copies are sent to facilities for Specialist care, school purposes,
insurance billing, or for Workers’ Compensation.
_______________________________________ _________ OR __________________________________________ _________
SIGNATURE OF PATIENT
DATE
PARENT/LEGAL GUARDIAN/AUTHORIZED PERSON
DATE
_______________________________________ _________
____________________________________________________
RECORDS RECEIVED BY
DATE
RELATIONSHIP TO PATIENT
PRESENTED ID: ______________________________ VERIFIED BY:________________________PROOF OF LEGAL GUARDIANSHIP: ________________
PROVICER REVIEWED: ____________________
D ATE ____________DATE REQUEST FILLED:_____________________ BY: __________________
FEE COLLECTED: ________________ WRITTEN REQUEST TO REVOKE (ATTACH) PROC’D BY:_______________________EFF DATE: _____________

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Legal
Go