Healthcare Attachment Form

HEALTHCARE ATTACHMENT FORM

Patient Information

Date of Birth:

Male    Female    Other    Prefer not to say

Emergency Contact

Insurance Information

Subscriber Date of Birth:

Medical History (Relevant to Attachments)

Attachment Details

Attachment Type (check all that apply):
Clinic Notes    Lab Results    Imaging / Radiology    Referral Letter    Billing / Insurance Documents    Other

Purpose & Use of Attachments

Intended Purpose (check all that apply):
Inclusion in medical record    Release to third party for continuity of care    Claims / insurance processing    Specialist referral    Other

Certification, Authorization, and Acknowledgment

I certify that the attached documents are accurate copies of records or information I am submitting for inclusion in the patient medical record or for release for the purposes indicated above. I authorize the facility and its agents to include, copy, and disclose the attached information as necessary for treatment, payment, and health care operations or as otherwise permitted by law.

I understand that information included with these attachments may contain sensitive medical information. I understand that, once disclosed to a recipient, my information may be subject to re-disclosure by the recipient and may no longer be protected by privacy law. The provider and facility are not responsible for content prepared by third parties that I supply.

I acknowledge that I may revoke this authorization in writing at any time, except to the extent that action has already been taken in reliance on this authorization. Any revocation must be submitted in writing to the records department identified by the treating provider.

I consent to the inclusion and use of these attachments for the purposes checked above:
I consent to inclusion of attachments in my medical record.
I consent to release of attachments to third parties for the purposes specified.

Acknowledgment of Privacy Notice:
I acknowledge that I have received or been offered a Notice of Privacy Practices that describes how my health information may be used and disclosed, and my rights with respect to that information.

This authorization will expire on:

Additional Instructions / Comments

Signer Certification

By signing below I certify that I am the patient or legally authorized representative of the patient, that I have the authority to execute this authorization, and that the information provided on this form is true and correct to the best of my knowledge. I understand that signing this form authorizes the use and disclosure described herein.

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