Healthcare RAADSR Form

Healthcare RAADSR Form

Patient Identification

Patient Name:    Date of Birth:

Gender: Male Female Other Decline to State

Emergency Contact

Insurance Information

Authorization to Release / Disclose Records

I authorize the release of my protected health information as described in this form from:

Treatment/Continuity of Care Billing/Claims Legal Proceedings Personal Use Transfer of Care Other:

Records To Be Released

Select the records to be disclosed (check all that apply):

Complete Medical Record Laboratory Results Radiology / Imaging Reports Immunization Records Billing / Account Records Prior Surgical Records Mental Health Records Substance Use Treatment Records HIV-Related Information

Sensitive Information Acknowledgment

State and federal law may require special authorization to release certain types of information. By initialing and/or checking the categories below, I specifically authorize release of the following sensitive information where applicable:

Mental health psychotherapy notes and therapy records
Records related to substance use disorder diagnosis and treatment
HIV/AIDS-related testing and treatment records
Genetic testing information

I understand that some of the above information may be subject to additional legal protections and that, where required, separate consent may be necessary. I further understand that disclosure of substance use disorder records may be protected under federal law and may not be re-disclosed absent written authorization.

Duration and Revocation

This authorization is effective immediately unless otherwise specified. Expiration:   through     or upon occurrence of the following event:

I understand that I may revoke this authorization at any time by submitting a written notice to the releasing provider at the address below, except to the extent that action has already been taken under this authorization.

Redisclosure & Limitations

I acknowledge that information disclosed pursuant to this authorization may be subject to redisclosure by the recipient and no longer protected by federal privacy rules, except where state or federal law expressly prohibits redisclosure of certain categories of information (including, but not limited to, substance use disorder treatment records and certain HIV-related information). The provider is not responsible for the actions of the recipient.

I understand that refusal to sign this authorization will not affect my eligibility for treatment, payment, enrollment, or benefits unless the information requested is necessary to determine those matters.

Fees for Copies

I understand that reasonable fees for copying and postage may be charged in accordance with applicable law. If applicable, fee arrangements should be confirmed with the releasing provider prior to release.

Patient Certification

By signing below, I certify that I am the patient or am authorized to act on behalf of the patient and that the information on this form is accurate. I authorize the release of the specified protected health information and understand its meaning and effect.

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