Authorization for Release of Information

Authorization for Release of Information (for Use and Disclosure)

Please fill out all sections or the form may be returned to you.

Patient Name: Social Security Number:

Address: Date of Birth:

City: State: Zip: Phone Number:

Type of Release

I would like records from the following dates: through

(This can be a very specific date or more general. Examples: July 15, 2007 or June 2006 - Feb 2007)

Please check the records you would like:

Records related to (specify):

Sharing of Special Protected Records: I authorize the sharing of information about:

Reason records are needed (check all that apply):

This Authorization will expire on (date):

If no date is included the Authorization will expire in 90 days.

- I understand that I may revoke this Authorization at any time, unless the Authorization was obtained as a condition of obtaining insurance coverage; that my revocation must be submitted in writing to the Registration Office at the Facility/location where I originally submitted/filed this authorization; and that the revocation shall be effective except to the extent that the Facility has already used or disclosed information in reliance on the Authorization.

- I further understand that treatment payment, enrollment in any health plan, or eligibility for benefits is not conditioned on signing this Authorization, however, Facility may condition the provision of health care that is solely for the purpose of creating protected health information for disclosure to a third party on my signing this Authorization, and Facility may condition the provision of research-related treatment on my signing this Authorization.

- I understand that information used or disclosed pursuant to this Authorization may be subject to re-disclosure by the recipient and may no longer be protected by applicable privacy law. I further understand that the facility, its employees, officers and agents are released from legal responsibility or liability for the use and disclosure of the above information to the extent indicated and authorized.

I have read and understand this information. I have received a copy of this form and I am the patient or am authorized to act on behalf of the patient to sign this document verifying authorization for the use or disclosure of the protected health information under the above stated terms.

If patient is unable to sign, secure consent of Legal Representative and indicate reason below:

Proof of designation must be filed in the chart or sent with this request.

TO PATIENTS OR LEGAL DESIGNEES:

FACTS ABOUT OBTAINING YOUR MEDICAL RECORDS:

You have the right to obtain a copy of your medical records. The law requires a signed authorization form which contains certain criteria included on this form. This form must be fully completed before any medical information can be released. Incomplete forms may be returned for completion.

COSTS:

Kentucky law allows you one free copy of your medical record. This free copy is one requested by you for yourself or for a third party. Additional requests will cost $1.00 per page. It is advised you keep a personal copy of any medical information you request to avoid future costs of obtaining copies.

WHEN AND HOW WILL I GET MY RECORDS?

The request will be completed within 30 days of receipt. You will be notified via mail if the records cannot be processed in 30 days. If you would like to pick up your records, indicate this on the form with a phone number where you can be contacted. Otherwise, records will be mailed to the address listed on the authorization.

WHERE TO SEND YOUR REQUEST

Mail a completed request form to one of the following addresses:

1) University of Kentucky Hospital
Release of Information Section
Health Information Management Dept.
Room C601
800 Rose Street
Lexington, KY 40536-0293

2) UK HealthCare Ambulatory Services
Release of Information Section
Health Information Management Dept.
Room K003
740 South Limestone
Lexington, KY 40536-0284

3) UK HealthCare Good Samaritan Hospital
Release of Information Section
Health Information Management Dept.
Room B128
310 South Limestone
Lexington, KY 40508-3008

4) UK College of Dentistry
Dental Records
800 Rose Street D-104
Lexington, KY 40536-0297

Or fax a completed request form to:

University of Kentucky Hospital (859) 323-6853
UK HealthCare Ambulatory Services (859) 257-7228
UK HealthCare Good Samaritan (859) 226-7037
UK College of Dentistry (859) 323-0271

Contact UK Health Connection if you have any questions:

Local (859) 257-1000
Toll-Free (800) 333-8874