Authorization For Use And Disclosure Of Health Information

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AUTHORIZATION FOR USE AND DISCLOSURE
OF HEALTH INFORMATION
Patient Name: ____________________________ DOB: ____________ MRN: _________
Address: _________________________ City: ____________ State: _______ Zip: ______
Phone: ________________________ Email (optional): ____________________________
Type of Access Requested:
[ ] Paper Copy
[ ] CD or USB Drive
[ ] Inspection Only
[ ] Email (encrypted)
[ ] Other (must be agreed upon by patient and provider): ___________________________
(Note: If you would like us to send information over email unencrypted, this increases the
risk that the information could be read by an unauthorized third party.)
Delivery Method Requested: [ ] Mail
[ ] Email
[ ] Pick-Up (If applicable)
Purpose of Requested Use or Disclosure:
[ ] Continuity of Care – Appointment Date with Physician: ___/___/_______
[ ] Patient
[ ] Insurance
[ ] Other: _________________
Authorization
I hereby authorize:
________________________________________________________________________
(Name of hospital, physician, healthcare provider)
________________________________________________________________________
Address
City
State
Zip
________________________________________________________________________
Phone
Fax
To release my health information to: [ ] Self (same address as above),
OR
________________________________________________________________________
(Name of individual, organization, medical provider)
Address
City
State
Zip
________________________________________________________________________
Phone
Fax
Information to be disclosed:
[ ] Complete Medical Record
[ ] History and Physical
[ ] Laboratory Test(s)
[ ] Outpatient Clinic Records
[ ] Consultation
[ ] Radiology Report(s)
[ ] Pertinent Information
[ ] Operative Report
[ ] Radiology Images:
(Hospital Only)
[ ] Discharge Summary
[ ] X-ray
[ ] Home Health and
[ ] Emergency
[ ] Ultrasound
Hospice Records
Physician Report
[ ] CT
[ ] MRI
[ ] Other: ______________________
[ ] Mammography
Specify date(s) of service for records requested: _______________________________
Revised 10/02/2013

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