Authorization for Release of Patient Health Information
INSTRUCTIONS: This authorization is made by you for the release of your healthcare information, as indicated. Please complete each
section. Sections NOT completed may delay the request of information being released.
SECTION 1 - Patient Information
Name:
Date of Birth:
Address (street, city, state, zip):
Phone Number(s):
Social Security Number (last 4):
xxx-xx-
_
Home
Cell
Business
SECTION 2 - Authorized To Request Use or Disclosure (FROM)
I request that my medical record information be sent FROM the person(s)/location(s) indicated below.
Organization:
Address (street, city, state, zip):
SECTION 3 - Authorized Recipient To Receive (TO)
I request that my medical record information be sent TO the person(s)/location(s) indicated below.
If you are requesting access to your own medical record, please fill in your own personal information.
Name:
Organization:
Address (street, city, state, zip):
Phone Number(s):
Home
Cell
Business
Fax
SECTION 4 - Purpose Of The Use or Disclosure (e.g. further care, insurance claim, attorney inquiry, personal use, etc.)
SECTION 5 - Disclosure To Include
The following information is authorized for release for the treatment dates of:
This disclosure will include the following types of reports (check all that apply):
Record Abstract (History and Physical, Emergency Room Record, Lab, Radiology, Operative Report, Pathology Report, Consultation Report, D/C
Imaging/Radiology Report
Operative Report
History and Physical
Pathology Report
Emergency Report
Consultation Report
Immunization Record
Itemized Bill
Progress/Physician Notes
Discharge Summary
EKG/EEG/EMG Report
Entire Chart
Laboratory Report
Other:
SECTION 6 – Highly Confidential Information To Be Disclosed
The following highly confidential items must be checked off to be included in the use or disclosure of health information:
HIV/AIDS related health information and/or records (the patient 12 or over must authorize this release)
Behavioral or Mental Health Information and/or Records (release must be witnessed and the patient 12 or over must authorize this release)
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Authorization for Release
of Patient Health Information
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