Authorization for Release of Medical Record Information

Authorization for Release of Medical Record Information
(Not to Be Used for a Patient Access Request)

I hereby authorize Lee Health to release my protected health information including information from my medical record which may include HIV (AIDS) testing, sexually transmitted disease, mental health and/or substance abuse services. I further release Lee Health from all legal responsibility and/or liability that may arise from the release of such records as specified above and I hereby waive all rights I have to preserve such records confidentiality. You may fax to (239) 343-4189 (Release of Information) or hand deliver to a Lee Health facility.

Patient’s Legal Name: Date of Birth:

Telephone: Address: City: State: Zip:

The information is to be: Mailed to ; Picked-up Date:

Electronic Delivery (additional form to be completed)

The request is subject to the limitations as listed below and is for the purpose of:

Personal Payment Healthcare Operations Other:

Treatment (Continued Care) Physician Appointment (Date/Time):

Please furnish the following:

Emergency Dept. Notes Consultation

Physician Office Notes Immunizations

Discharge Summary Physician Orders

Operative Record HIV Results (AIDS Testing)

History & Physical Exam Progress Notes

Pathology Report Laboratory Results

Radiology Tests Diagnostic Tests

Psychiatric/Psychological Testing (Mental Health) Other:

This authorization is for the listed date(s) of treatment:

From (Date): To (Date): Special Instructions:

I further agree to pay fees charged to provide the information requested. I understand that fees are within the fee allowed by Florida Law. The fees are waived only if the copies are forwarded directly to a physician office and/or health care provider.

I understand that this authorization is voluntary and that I may refuse to sign it. Lee Health will not condition treatment, payment, enrollment in a health plan, or eligibility for benefits on the individual providing authorization of the requested use as stated above. This authorization may be revoked except to the extent that action(s) have been taken as outlined by this authorization. The revocation must be in writing to the Lee Health Privacy Officer by mail to Privacy Officer P.O. Box 2218, Fort Myers, FL 33902 or e-mail at PrivacyOfficer@LeeHealth.Org. I understand that I have the right to inspect or copy the protected health information to be used or disclosed pursuant to this authorization. Information used/disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and no longer protected by Federal Privacy Rules.

If the legal representative, sign below and state relationship and authority to do so and attach a copy of the document of authority.

This authorization is in effect until or for 1 year from the date signed.

Consent to Minors

Minors are permitted to consent to medical care and treatment in the following situations. Thus, the parents are not entitled to the minor’s information without written consent of the minor, a valid subpoena or court order.

1. A minor who is, or has been, married.

2. An unwed pregnant minor consenting to the performance of medical or surgical care or services relating to her pregnancy.

3. An unwed minor mother consenting to the medical or surgical care or services of her child.

4. A minor seeking voluntary substance abuse impairment services.

5. A minor consenting to the examination and treatment of a sexually transmitted disease.

6. A minor receiving contraceptive information or services.

7. A minor with a court order removing the disability of nonage.

8. Unless a parent objects in writing, any minor who has reached the age of 17 years may give consent to the donation, without compensation therefore, of his blood and to the penetration of tissue which is necessary to accomplish such donation.