Healthcare Release of Information Consent

HEALTHCARE RELEASE OF INFORMATION CONSENT

Patient Name:    Date of Birth:    Gender:

RECIPIENT / RECIPIENT INFORMATION

I authorize the following entity or person to receive the protected health information described below:

DISCLOSURE AUTHORIZED FROM

Release records FROM (facility, practice, or provider holding records):

INFORMATION TO BE RELEASED

Select specific records to be released. If uncertain, specify date range or check Whole Record.

Whole medical record (excluding records specifically restricted below unless also authorized)

Progress notes Laboratory results Imaging reports and films Operative and procedure reports Pharmacy / medication records Billing and financial records Immunization records Other clinical records

Date range for records to be released (if not whole record): From to

SENSITIVE INFORMATION - SPECIFIC AUTHORIZATION

I understand that certain information is protected by specific laws and requires explicit authorization. Check each category you AUTHORIZE to be released. If not checked, these records will not be released.

Mental health / psychotherapy notes Substance use treatment records (including alcohol/drug abuse) HIV/AIDS related information and test results Genetic testing and counseling records Reproductive health and pregnancy-related records

PURPOSE OF DISCLOSURE

Purpose for disclosure (check one or specify):

Continuing medical care Insurance or payment Legal purposes Personal use Other

FEES, REDISCLOSURE & AUTHORIZATION DURATION

I understand that a reasonable fee for copying and postage may be charged in accordance with law. I understand that once information is disclosed to the recipient it may be subject to redisclosure by the recipient and may no longer be protected by federal privacy regulations.

This authorization will expire on or upon the following event:

REVOCATION AND EFFECT OF REFUSAL

I may revoke this authorization at any time by providing a written notice to the releasing provider, except to the extent that action has already been taken in reliance on this authorization. Revocation does not affect disclosures already made in reliance on this authorization.

I understand that treatment, payment, enrollment, or eligibility for benefits may not be conditioned on signing this authorization except where permitted by law.

RIGHT TO INSPECT & COPY

I understand I may inspect or obtain a copy of the health information described on this form by contacting the releasing provider in accordance with their policies.

ACKNOWLEDGMENT & CERTIFICATION

By signing below I authorize the release of the protected health information as described above. I certify that I am the patient or an individual authorized to act on behalf of the patient, and that the information I have provided is true and accurate. I understand that this authorization is voluntary and that I may request a copy of this form.

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