McFarland Clinic Health Care Power of Attorney Form

McFarland Clinic PC
Authorization to Release Protected Health Information

I understand that if the person(s) and/or organization(s) listed below are not health care providers, health plans, or health care clearinghouses, who must follow the federal privacy standard, the health information disclosed as a result of this authorization may no longer be protected by the federal privacy standards, and my health information may be re-disclosed without obtaining my authorization.

This authorization will automatically expire one year from date of signature or until , 20 . I understand that I may revoke this authorization at any time by notifying the providing organization in writing, but if I do, it will not have any effect on the actions they took before they received the revocation.

Any refusal to sign this form will not affect my ability to obtain treatment, payment or my eligibility for benefits. I may request to inspect or copy the health information to be used or disclosed. This release is not valid if it does not contain the patient signature.

Patient Information:

Name
Date of Birth
Medical Record Number

Previous Name

Street Address
City
State
Zip Code

Daytime Phone Number

I understand this does not include any correspondence/records generated from non-McFarland facilities. Those will need to be obtained from that particular facility.

Medical Information to be released:

Office Notes (this will be limited to 2 years of information including lab and x-ray, unless otherwise specified)

Lab     Pathology     X-Ray Reports     X-Ray films, images     OB Flow Sheet

Physical Therapy     Immunizations     Cardiovascular images     EKG

Billing Information     Other-Specify

For date(s) of treatment or condition

The information disclosed may include matters regarding mental health/depression, alcohol or drug abuse, infectious diseases, including HIV and genetic testing information. Refusal to consent to release information will result in such confidential records not being released.

If you do not wish such information to be released, state information to be excluded:

I am requesting this information to be released for the following purpose:

Medical Treatment     Transfer of Care     Worker's Compensation     Insurance     Disability

At My Request     Legal     Moving     Other

A copy of this signed form will be provided to the patient.

Legal documentation is required supporting his/her authority to act on a patient's behalf.

Photo identification will be requested for all hand carry release of information requests. Facsimile reproductions of the signature are acceptable. There is a service fee for medical record transfer requests.

For Clinic Use

Reviewed and approved by
Dr.
Processed by

Date Approved
Date Completed