Healthcare Crane Center ROI

HEALTHCARE CRANE CENTER AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION (ROI)

Patient Name:    Date of Birth:    Medical Record No.:

Authorization — Parties and Purpose

I authorize Healthcare Crane Center to release my protected health information as described below.

Information To Be Released

Check the specific information to be disclosed. If sensitive information is requested, my explicit consent is required by law and is provided by selecting the corresponding item(s).

Time Period

Release records from:    to       OR All dates of service

Method of Disclosure

Provide records by (select all that apply):
Paper copy (mail or pick up)
Patient or representative pick up in person
Fax:
Unencrypted email (I understand risk of interception): Email address
Secure electronic portal / CD
Other:

Fees

I understand that Healthcare Crane Center may charge a reasonable fee for copies of records and postage when applicable. Charges will be provided upon request unless prohibited by law.

Expiration and Revocation

This authorization will expire on: . If no date is provided, this authorization will expire 180 days from the date signed unless otherwise specified here:

I understand that I may revoke this authorization at any time by providing a written notice to Healthcare Crane Center, except to the extent that action has already been taken in reliance on this authorization. Revocation should be addressed to:

Redisclosure Notice and Legal Rights

I understand that information disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and no longer protected by federal privacy regulations. Certain types of information (including substance use treatment records, HIV-related information, genetic testing, and psychotherapy notes) may have additional state or federal protections. By selecting such categories above, I specifically authorize their release and acknowledge the additional protections.

Signing this authorization is voluntary. My treatment, payment, enrollment, or eligibility for benefits will not be conditioned on signing this authorization except where allowed by law (for example if the purpose is to obtain eligibility or enrollment in a health plan).

I acknowledge that I have received a copy of this authorization.
I understand my rights as described in this authorization and that I may revoke this authorization in writing.

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