Healthcare DR Document

HEALTHCARE DR DOCUMENT

This Healthcare Designated Representative and Medical Release ("DR Document") authorizes the disclosure of protected health information and designates an individual or entity to act on behalf of the patient for purposes described below. The patient named below hereby provides specific authorizations, acknowledges rights, and understands conditions and limits of this authorization as set forth in this document.

Patient Information

Date of Birth:    Gender: Male Female Other

Emergency Contact

Designated Representative

Relationship to Patient:

Scope of Authorization

The patient authorizes the release and disclosure of the following categories of protected health information to the designated representative (check all that apply):

Medical records (including diagnoses, treatment notes)    Billing and insurance records    Prescription and medication history    Laboratory and imaging results

Additional limitations or specific records to include/exclude:

Methods authorized for release (check all that apply): Mail Fax Secure Email In-person Pickup

Permission to authorize third-party release or sub-delegation: Yes No

Purpose of Disclosure:

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

Medical History (for representative reference)

Authorization, Rights and Legal Terms

By signing below, the patient authorizes any physician, health care provider, health plan, or hospital to disclose the protected health information described in this document to the designated representative. This authorization is voluntary and may be revoked at any time in writing, except to the extent that action has already been taken in reliance on it.

The patient understands that information disclosed pursuant to this authorization may include records relating to communicable diseases, behavioral or mental health, HIV/AIDS testing and status, substance use disorder treatment, genetic testing, and other sensitive categories unless explicitly excluded above. The patient hereby specifically consents to disclosure of such sensitive information unless the box below indicates exclusion.

Exclude sensitive categories (check all that apply): HIV/AIDS    Mental Health Records    Substance Use Treatment

The patient acknowledges 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. The patient understands that the provider may charge a reasonable fee for copying and mailing records as permitted by law.

Revocation: To revoke this authorization, the patient must provide a written notice to the health care provider that issued the records, identifying this authorization and the date of revocation. Revocation will not affect disclosures made in reliance upon this authorization prior to receipt of the revocation.

HIPAA Acknowledgment

I acknowledge that I have been informed of my rights concerning the use and disclosure of my protected health information and that I have the right to receive a copy of this authorization upon request. I understand that I may refuse to sign this authorization and that my refusal will not affect my ability to obtain treatment, payment, enrollment in a health plan, or eligibility for benefits unless allowed by law.

Acknowledgment of receipt of notice and understanding of rights: I acknowledge and understand

Patient Certification

By signing below I certify that I am the patient or the patient's legally authorized representative. I certify that the information I have provided is true and accurate to the best of my knowledge and that I have the authority to execute this authorization on behalf of the patient.

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