Healthcare Data Download

HEALTHCARE DATA DOWNLOAD

This form authorizes the release and electronic download of protected health information (PHI) held by the Covered Entity identified below to the requestor or designated recipient named herein. Completion of this form constitutes a specific, informed authorization for disclosure for the purpose and scope described. Patient Name:

Patient Information

Male Female Other Prefer not to say

Request Details

I request download of the following types of health information (check all that apply):

Clinical notes and visit summaries Laboratory results Imaging reports (not images) Imaging files (DICOM, JPEG) Medication list and prescription history Immunization records Billing and insurance records Entire medical record Other:

Secure patient portal download Unencrypted email (recipient accepts risk) Encrypted email Encrypted USB drive (pick up or mail) CD/DVD Paper copies

Purpose of Request

Authorization and Legal Notice

By signing below, I hereby authorize the Covered Entity to compile and disclose the categories of protected health information described above and to make such information available for electronic download or physical delivery as specified. I understand that this authorization specifically authorizes disclosure of sensitive categories of information where included in the record, including but not limited to mental health treatment notes, HIV-related information, substance use disorder treatment records, and genetic test results, unless I have specifically excluded such categories here:

I understand that: (1) the entity may charge a reasonable, cost-based fee for copying and delivery and that I will be advised of any fees prior to processing; (2) requested information will be provided within a reasonable period as required by law; (3) information disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and may no longer be protected by federal privacy regulations; and (4) I may revoke this authorization at any time in writing, except to the extent the entity has already acted in reliance on it.

I acknowledge I have received the Notice of Privacy Practices or have been offered a copy. I understand I may be charged a reasonable fee for copying and delivery. I understand that I may revoke this authorization in writing, subject to processing exceptions described above.

Identity Verification

Presented government-issued photo ID in person Remote identity verification (photograph of ID provided) Known patient account verification

Expiration of Authorization

This authorization will expire on:   or upon earlier written revocation.

Representative Acting for Patient (if applicable)

By signing, I certify that I am the patient or the patient's duly authorized personal representative, that the information provided on this form is true and correct, and that I understand the consequences of authorizing disclosure of my protected health information as described above. If signing as a personal representative, documentation of authority must be provided upon request.

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