Healthcare DC Document

HEALTHCARE DC DOCUMENT — AUTHORIZATION FOR DISCLOSURE OF PROTECTED HEALTH INFORMATION

Patient Name:    Date of Birth:

Patient Information

Insurance Information

Medical History (for release context)

Recipient of Information

Purpose of Disclosure

Purpose (check all that apply):
Continuing care / treatment    Insurance / claims    Legal representation    Personal use    Other:

Description of Information to Be Disclosed

Select the specific categories of information to be disclosed:
All medical records (including billing)
Billing, payment, and claims records
Laboratory and imaging reports
Progress notes and clinical documentation
Mental health records (psychotherapy notes excluded unless specified)
HIV-related information
Substance abuse treatment records
Genetic testing results
Other (specify):

Authorization Period / Expiration

This authorization will expire on: . If no date is provided, this authorization will expire one year from the date of signature unless otherwise required by law.

Right to Revoke

I understand that I may revoke this authorization at any time by delivering a written revocation to the Privacy Officer or the health care provider listed on the patient's record. Revocation will not affect disclosures made in reliance on this authorization prior to receipt of the revocation.

Redisclosure and Limitations

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. I also understand that certain types of information (for example, psychotherapy notes, HIV-related information, substance abuse treatment records, and genetic testing results) may require a separate authorization; by specifically selecting such categories above I affirmatively authorize their release as indicated.

Fees for Copies

I acknowledge that reasonable fees for copying and postage may be charged in accordance with applicable law and the provider's policies. I understand that I will be informed of such fees prior to fulfillment when required.

Acknowledgment

By signing below I certify that I am the patient or I am the patient's personal representative and have authority to act on the patient's behalf. I understand the nature and purpose of this authorization and request that the health information described above be disclosed as specified.

I acknowledge that I have received a copy of this signed authorization: Yes

Patient Certification / Consent

I authorize the release of the protected health information described above to the recipient named in this document. I understand that I may refuse to sign this authorization and that the refusal will not affect my ability to obtain treatment, eligibility for benefits, or payment for health care.

Initials for consent to release sensitive categories (if applicable):
Mental health records:    HIV-related:    Substance abuse:    Genetic testing:

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