Healthcare ER Letter

EMERGENCY DEPARTMENT VISIT SUMMARY / AUTHORIZATION

Facility and Provider

Facility Name:    Address:

Attending Clinician:    Contact (phone):

Patient Information

Visit Details

Date of Visit:    Time of Arrival:    Time of Departure:

Vital Signs on Arrival:

Disposition and Diagnosis

Final Diagnosis / Assessment:

Discharged to home    Admitted to inpatient service    Transferred to another facility    Left against medical advice

Aftercare Instructions & Restrictions

Work/Activity Restrictions:

Recommended Duration of Restrictions:    Return-to-Work / Follow-up Appointment With:

Authorization to Release Information

I authorize the release of relevant medical information contained in this Emergency Department summary to the following recipient(s) for continuity of care or employment verification (select all that apply):

Primary care provider    Employer/Workplace    Specialist / Consultant    Other:

Purpose of Release:

Privacy Acknowledgment

I acknowledge that I have been provided with the facility's Notice of Privacy Practices regarding the use and disclosure of my protected health information and that information in this summary may contain protected health information.

Patient acknowledges receipt of privacy notice

Certification

By signing below, I certify that I am the patient named above or the lawful representative of the patient. I authorize the facility named above to release the medical information described in this document to the recipient(s) identified for the purpose stated. I understand that this authorization is voluntary and that treatment will not be conditioned on signing this form unless the information is required for payment or specific administrative purposes. I understand that revoked authorizations must be submitted in writing and do not apply to disclosures already made in reliance on this authorization.

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