Authorization For Release Of Medical Information

ADVERTISEMENT

AUTHORIZATION FOR RELEASE
OF MEDICAL INFORMATION
Records to be released from:
CMC
Ahuja
Bedford
Conneaut
Elyria
Geneva
Geauga
Parma
Portage
Richmond
UH Home Care
UHPS
Samaritan
St. John
Patient Name
(Please Print)
Last
First
M/I
Date of Birth
Social Security Number (last four digits)
Address
Phone Number (
)-
Medical Record Number
Prior MR #
Treatment Date(s)
Please Release Medical Information to the Following Recipient:
Name of Person or Organization
Phone #
Address
Mailstop
Fax #
City
State
Zip Code
Purpose of Disclosure
at the patient's request
Description of Information to be Released:
Pertinent Summary (includes all * items)
Admission Form
Facesheet / Demographics
Physical Therapy
*Discharge Summary
Lab Reports
Entire Record
*Emergency Room Report
*Radiology Report
Physician's Notes
Other
*History & Physical
*EKG Report
*Consultation Report
*Pathology Report
*Operative Report
*Card Cath Report
I, the undersigned, authorize
(Disclosing Institution) and its employees to
release Information from my medical records as described above. I understand and acknowledge that the medical record may contain
Information regarding psychiatric disorders, Human Immune Virus (HIV) test results, Acquired Immune Deficiency Syndrome (AIDS),
AIDS-related conditions, alcohol, and/or drug dependence/abuse. I also understand that Information used or disclosed according to this
authorization may be subject to redisclosure by the recipient and may no longer be protected. My failure to sign this authorization may
result in my Information not being released.
I understand that I have a right to revoke this authorization at any time. I understand that if I revoke this authorization I must do so in
writing and present my written revocation to the health information management department. I understand that the revocation will not
apply to information that has already been released in response to this authorization. I understand that the revocation will not apply to my
insurance company when the law provides my insurer with the right to contest a claim under my policy. Unless otherwise revoked, this
authorization will expire on the following date, event, or condition:
. If I fail
to specify an expiration date, event or condition, this authorization will expire in one year.
I understand that treatment, payment, enrollment, or eligibility for benefits will not be conditioned on my failure to sign this authorization.
I understand there may be charges for the copying and release of Information and accept financial responsibility.
X
/
/
Signature of Patient/Legal Representative**
Date Signed
Patient unable to sign
Description of Legal Representative's Authority to Act on Behalf of Patient (if applicable)
By signing this form as the patient's legal representative, I am certifying that there is no court order or other legal reason (such as a
binding arbitration decision or final mediation agreement) prohibiting me from obtaining a copy of the requested records.
This box must be checked for ALL releases of records authorized by legal representatives.
**If other than patient's signature, a copy of legal documents MUST accompany the authorization when presented; the exception is a parent of minors under 18 years of age.
SP13018 Authorization for Release of Medical Information (8/16)
803233

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Business
Go