Authorization To Release Medical Records Or Protected Health Information printable pdf download

Authorization to Release Medical Records or Protected Health Information

Patient Name: _________________________ Date of Birth: _____________SS#: ______________

Date of Visit(s) Needed: __________________MR#:_____________ Account(fin)#:______________

I hereby authorize: □ Pardee Hospital or □ Other facility: ___________________________________

To share information with (Address or Fax number) ____________________________________

□

STAT Patient is in our Facility

Please Fax To: ____________________________

The medical information or part of the medical record that will be shared includes:

□ Abstract □ Whole Chart □ ER visit □ Dictation □ Labs□ (mailed only)_________□ Radiology

□ EKG □ Pain Clinic Notes □Paths notes

The purpose of this release is: □ Continued care_______________ □ Legal__________________

□ Insurance □ Disability □ Personal □ Social Security ID Purpose □Dates of Service (only)

I understand that:

I am authorizing the health care provider listed to provide copies of my medical record even though it may

contain private information about: rape, abuse (sexual, physical, elder, spousal, etc), genetics, abortion,

sexual disease, illnesses like hepatitis or AIDS, ARC (AIDS-related complex), HIV and AIDS testing,

substance abuse, and/or mental illness.

The health care provider listed above has no control over how my medical records will be used by the

people who receive them. These people may copy and provide my medical records to other people who

do not have to obey state or federal laws protecting the privacy of medical records.

My decision to sign this authorization will not affect the treatment provided to me by the health care

provider, the cost of that treatment or my benefits.

I may ask for and get a copy of this authorization.

A readable photocopy/fax of this authorization shall have the same force and effect as the original.

This authorization will expire in 90 days (or unless a date or event is written).

I can cancel this authorization at any time by writing to the health care provider’s Privacy Officer or Health

Information Management Department at the address listed below. I understand that canceling will not affect

my insurance company’s right, if any, to contest a claim under my policy. I also understand that my

cancellation may not apply to information already sent out.

I release the health care provider, its employees, officers and physicians from any legal responsibility or

liability for this disclosure to the extent indicated and authorized.

THIS AUTHORIZATION WILL BE USED TO FAX EMERGENCY INFORMATION.

_________________________________________________ Date: _______________________

Patient or Representative Signature

□ Parent □ Legal Guardian □ Executor of Estate □ Next of Kin □ Healthcare Power of Attorney

______State Drivers License Verified

_____Signature was verified from chart

Employee’s Badge# ________

_________________________________________________ Date: _______________________

Witness or Hospital Staff

Patient Label

Mailing Address: 800 North Justice St. ● Hendersonville, NC 28791

General Phone (828) 696-1096 or 696-1094 ● Fax (828) 696-1097

9615-05 (10/11/2012)

Authorization To Release Medical Records Or Protected Health Information

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