Healthcare PHI Provider Form

HEALTHCARE PHI PROVIDER FORM

Authorization to Use and Disclose Protected Health Information (PHI)

I authorize the disclosure of my protected health information as described below. I understand that this authorization is voluntary, that treatment, payment, enrollment, or eligibility for benefits may not be conditioned on signing this authorization, and that information disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and may no longer be protected by federal privacy regulations.

Patient Information

Patient Name:

Date of Birth:    Gender: Female Male Other

Provider Releasing PHI

Phone:    Fax:

Recipient / To Whom Disclosed

Recipient Phone:    Recipient Fax:

Purpose of Disclosure

Purpose (select all that apply): Treatment Billing/Payment Insurance Claim Legal At Patient's Request Other

Information to Be Disclosed

Select the specific records to be disclosed (select all that apply). If no box is selected, this authorization will be interpreted as authorizing release of the entire medical record for the dates specified below.

Entire Medical Record    Laboratory Results    Radiology / Imaging Reports    Consultations    Medication Records

Mental Health Records (excluding psychotherapy notes)    Psychotherapy Notes (separate authorization required)   

HIV-Related Information (initial to authorize): Initials

Substance Use Disorder Treatment Records (initial to authorize): Initials

Genetic Testing Results (initial to authorize): Initials

From:    To:

Authorization Period and Revocation

This authorization expires on: . If no date is provided, this authorization expires one year from the date signed.

I understand that I may revoke this authorization at any time by submitting a written revocation to the releasing provider identified above, except to the extent that action has already been taken in reliance on this authorization. To revoke, provide revocation to: Name , Address , Phone

Fees and Method of Disclosure

Copies of records may be subject to reasonable fees for copying, postage, and preparation as permitted by law. Please indicate preferred method of disclosure:

Mail    Fax    Secure Electronic Transfer    Patient Pickup

Medical / Insurance Summary (optional)

Acknowledgements and Certifications

By signing below I certify that I am the patient or am authorized to act on behalf of the patient and that the information provided is true and correct. I understand that:

1. The recipient may redisclose information and it may no longer be protected by federal privacy regulations.
2. I may revoke this authorization in writing at any time, except to the extent that the disclosed party has acted in reliance on it.
3. This authorization is subject to any legal exceptions described herein; certain records (for example, psychotherapy notes) may require a separate authorization.
4. Fees for copying and transmission may apply as permitted by law.

I acknowledge that I have read and understand the terms of this authorization and that I have received a copy of this form upon request.

Signature

Relationship to Patient (if signed by proxy):

Sign Now