Healthcare Health Information Management Form

Healthcare Health Information Management Form

Patient Information

Date of Birth:    Gender:

Phone:    Email:

Emergency Contact

Relationship:    Phone:

Insurance Information

Policy Number:    Group Number:

Medical History (for Record Indexing)

Authorization for Release / Use of Health Information

I authorize the health care provider and its Health Information Management department to disclose the following protected health information to:

Recipient Name:    Recipient Address:

Purpose of Disclosure (check all that apply):

Treatment    Billing/Claims    Legal    Personal Use    Other:

Specific categories of information to be released (check all applicable):

Complete medical record (all documentation)
Progress notes / clinic notes
Operative reports / procedures
Laboratory reports
Imaging reports and films
Immunization records
Billing, claims, payment records
Mental health records (specify below if limited)
Substance use disorder treatment records (explicit authorization)
HIV/AIDS related testing and treatment records (explicit authorization)
Psychotherapy notes (NOTE: separate authorization may be required)

Records to be released for the period from to .

Method of Disclosure (check one or more):    Paper copy    Secure electronic file (encrypted)    Fax to:    Mail to recipient address    Pick up in person (ID required)

Conditions, Rights, and Notices

This authorization permits disclosure of the protected health information specified above to the recipient identified. The recipient may use the information for the purposes stated, but once disclosed the information may be re-disclosed by the recipient and may no longer be protected by federal privacy rules.

I understand that I may revoke this authorization at any time by delivering a written notice of revocation to the Health Information Management department, except to the extent that action has already been taken in reliance on this authorization. Revocation will not affect disclosures made prior to receipt of the revocation.

This authorization will expire on , or upon the following event: . If no expiration is specified, this authorization will expire 12 months from the date of signature.

I understand that treatment, payment, enrollment, or eligibility for benefits may not be conditioned on signing this authorization except where permitted by law. I understand that fees for copying and postage may be charged in accordance with applicable law and facility policy.

Psychotherapy notes, as defined under applicable privacy law, and certain substance use disorder records may require separate authorization. By checking the items above I affirm that I knowingly authorize release of those categories where explicitly indicated.

I acknowledge that I have been provided with or offered a copy of the facility's Notice of Privacy Practices.

Certification and Signature

By signing below, I certify that I am the patient or I am authorized to act on behalf of the patient as the patient's personal representative. I have read and understand the terms of this authorization, and I authorize disclosure as indicated above. I understand the limits on revocation and the potential for redisclosure.

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