Patient Authorization To Release Protected Health Information (Page 2 of 2) in pdf

ADDITIONAL INFORMATION REGARDING RELEASE OF HEALTH INFORMATION

Dean Clinic recognizes the patient’s right of confidentiality of their health information under federal

privacy regulations and Wisconsin law. The patient should be aware of the following information

when requesting or releasing health information.

Right to Refuse to Sign This Authorization: A patient may refuse to sign this Authorization and

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this refusal will not affect the patient’s ability to obtain treatment or payment of claims.

Right to Inspect or Copy the Health Information to Be Used or Disclosed: A patient has the right to

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inspect or copy the health information they have authorized to be used or disclosed by signing this

Authorization form. A patient may arrange to inspect their health information by contacting the

office listed below.

Right to Receive Copy of This Authorization: A patient has the right to receive a copy of the

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signed Authorization form.

Right to Revoke This Authorization: A patient has the right to revoke this Authorization at any time

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by giving written notice of revocation to the Privacy Officer listed below. Revocation of this

Authorization will not affect any action taken in reliance of this authorization before receipt of the

written notice of revocation.

Multiple Releases of Information: A patient may request multiple releases of the information stated

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on the Authorization form. However, all releases based on this form are limited to records dated up

to and including the date of the patient’s signature. A new Authorization is necessary for release of

information for care provided after the date of the patient’s signature, unless the Authorization

specifically states that specific records that will be generated in the future may

be released, for example “future records of a specific test” or “f u t u r e records of specific clinic

appointment.”

Who May Sign This Authorization:

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Generally, all patients 18 years of age and older must sign for release of their own health

information unless the following conditions apply:

a. The patient is incompetent

b. The patient is disabled and cannot sign the form

c. The patient is deceased. (A surviving spouse or personal representative of the estate

may sign. If there is no surviving spouse or personal representative, then an adult

member of the immediate family may sign.)

All persons signing for release of health information on behalf of the patient must state their

relationship to the patient and provide proof of legal authority of their capacity to act for the

patient.

Minors: Patients less than 18 years of age must sign for release of their health information in

the following cases:

a. Alcohol or other drug abuse treatment: age 12 or older

b. Mental health treatment: age 14 or older may consent to release of records without

parental consent (Parents also retain the right to access this information.)

c. HIV test results: age 14 or older

d. Emancipated minors who are married or in the military

Fees for Records: Dean Clinic may charge a reasonable fee for viewing, copying, postage and

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preparation of records to fulfill this request. All fees are based on the applicable laws governing

release of health information.

Contact Office: Requests for release of health information can be directed to the Medical Records

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Department or other appropriate department at the site where the services were provided.

All questions regarding federal privacy regulations can be directed to:

Dean Clinic Privacy Officer

1808 West Beltline Highway, Madison, WI 53713

Telephone: (608) 250-1075

Patient Authorization To Release Protected Health Information Page 2

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