Healthcare Interview Release Form

HEALTHCARE INTERVIEW RELEASE FORM

Patient Information

Patient Name:

Month: Day: Year:

Male    Female    Other / Prefer to self-describe:

Insurance Information

Medical History (brief)

Interview Details

Interview Date: Month Day Year

Authorization to Record and Release

I hereby authorize the recording and use of my interview as indicated below. I understand that the interview may include protected health information as defined under applicable privacy laws. I authorize the release, use and disclosure of my information as described and acknowledge that this authorization is voluntary unless required for treatment or payment.

Audio recording    Video recording    Photographs    Written transcript/summary

Research and clinical education    Publication in professional materials    Training and internal quality improvement    Public relations and marketing (limited use)

I consent to disclosure to third parties as necessary for the permitted uses:

Terms, Limitations and Acknowledgments

I understand and agree that (a) recordings, transcripts and photographs may be stored, duplicated and disseminated for the permitted uses; (b) I will not receive compensation for the use of these materials unless a separate written agreement is executed; (c) the provider and its agents are released from liability for any claims that may arise out of the authorized use consistent with this release.

I further understand that I may revoke this authorization at any time by providing written notice to the health care provider, but that revocation will not affect disclosures already made in reliance on this authorization prior to receipt of the revocation. I understand that information disclosed pursuant to this authorization could be re-disclosed by the recipient and may no longer be protected by privacy regulations.

This authorization will expire on: Month Day Year   or Perpetual until revoked in writing

By signing below I specifically authorize the release of my protected health information as necessary to accomplish the permitted uses described in this form. I acknowledge that I have been given the opportunity to ask questions about the use and disclosure of my health information and that the information to be released may include sensitive clinical material.

Certification

I certify that I have read and understand this Healthcare Interview Release Form, that the information provided is true and complete to the best of my knowledge, and that I am signing of my own free will. If signing as a legal representative or guardian, I certify that I have authority to execute this release on behalf of the patient and that documentation of such authority is available upon request.

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