Healthcare Extension Forms

HEALTHCARE AUTHORIZATION EXTENSION FORM

Patient Information

Date of Birth:    Gender: Male Female Other

Insurance Information

Medical History (Relevant)

Original Authorization Details

Original Authorization Date:

Type of original authorization (select all that apply):
Treatment Release of Records Billing/Claims Other

Extension Request

I request an extension of the original authorization to continue after the original expiration for the period beginning through .

Purpose of the extension:

Scope of information to be extended (check all that apply):

Complete medical record Mental / behavioral health records HIV-related information Substance abuse treatment records Billing / payment information

Notice of Rights and Conditions

By signing below, I certify that I am the patient or the patient's legally authorized representative and that I authorize the extension of the specific authorization described above. I understand that:

• this extension permits continued use and disclosure of protected health information as specified in the scope above;
• I may revoke this extension at any time by providing a written revocation to the health care provider or facility, but revocation will not affect disclosures made in reliance on the extension prior to receipt of the revocation;
• the extension does not authorize redisclosure by the recipient where such redisclosure is prohibited by law; however, information already disclosed to third parties may no longer be protected;
• I understand that refusal to sign this extension will not condition treatment, payment, enrollment, or eligibility for benefits, except where allowed by law; and
• I may be charged reasonable fees for copies of records when applicable and permitted by law.

Interpreter required: If yes, Interpreter Language:

Acknowledgment: I have read and understand this Extension Form and the rights described herein. I acknowledge receipt of the facility's privacy practices and understand that a copy of this form is valid as an original.

Authorization expiration date (if different from extension end date):

Certification

I certify under penalty of law that the information I have provided on this form is true and correct to the best of my knowledge. I understand that intentional falsification may subject me to criminal or civil penalties as provided by law.

Patient/Representative acknowledges receipt of a copy of this extension:

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