Healthcare CDA Final

HEALTHCARE CDA FINAL

Patient Information

Date of Birth:    Gender:    Medical Record No.:

Phone:    Email:

Insurance Information

Policy Number:    Group Number:    Subscriber Name:

Medical History / Clinical Data Summary

Clinical Data Access Authorization

I hereby authorize the release and disclosure of my protected health information as described below. This authorization is voluntary and is given for the specific purpose(s) and to the specific recipient(s) identified in this form.

Medical history and progress notes    Laboratory results    Imaging reports and films    Consultation reports

Billing and insurance records    Other (specify):

Release of sensitive information (check to authorize specific sensitive categories):
HIV/AIDS test results and records    Mental health / psychiatric records    Substance abuse treatment records    Genetic testing records

Method of disclosure (select all that apply):
Paper copy    Electronic copy (secure transfer)    Fax transmission

Time period of records to be disclosed: From to

This authorization will expire on: . If no date is provided, this authorization will expire 12 months from the date of signature.

Rights, Revocation, and Redisclosure

I understand that I may revoke this authorization at any time by providing a written revocation to the health information custodian named above, except to the extent that action has already been taken in reliance on this authorization. Revocation will not affect disclosures already made in reliance on this authorization prior to receipt of revocation.

I understand that information disclosed pursuant to this authorization may be subject to redisclosure by the recipient and may no longer be protected by federal privacy regulations. Redisclosure may be prohibited by applicable state law for certain sensitive information but cannot be guaranteed.

I understand that treatment, payment, enrollment, or eligibility for benefits may not be conditioned on signing this authorization unless the provision of such treatment is solely for creating the medical record for disclosure to a third party.

Fees and Charges

I acknowledge that a reasonable, cost-based fee may be charged for copying and mailing or transmitting records. I agree to pay such charges as permitted by law unless exempted.

Patient Certification

By signing below I certify that I am the patient or the patient's legally authorized representative, that I have read and understand this form, and that the information provided is true and correct to the best of my knowledge. I understand the scope and limitations of this authorization and consent to the release of the specified records.

If signing as a legal representative, indicate authority:

Additional Instructions / Special Handling

Relationship to Patient (if not patient):

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