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SAMPLE

AUTHORIZATION FOR RELEASE OF CONFIDENTIAL INFORMATION

  

 

     

Patient’s Full Name

 

Patient’s Social Security Number/Medical Record Number

     

 

Address

 

Patient’s Date of Birth

     

 

     

City, State Zip Code

 

Patient’s Telephone Number

I hereby authorize use or disclosure of protected health information about me as described below.

1.        The following specific person/class of person/facility is authorized to use or disclose information about me: 


                 __________________________________________________________________________________________

 

2.        The following person (or class of persons) may receive disclosure of protected health information about me:

    

His/her/its Name:

 

Address

     

City, State Zip Code

3.        The specific information that should be disclosed is (please give dates of service if possible): 

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

UNLESS YOU SIGN HERE, NO INFORMATION ABOUT ALCOHOL/SUBSTANCE ABUSE, HIV/AIDS, OR MENTAL HEALTH WILL BE DISCLOSED:

 

YES, DISCLOSE THIS INFORMATION  *____________________________________________________________________

 

NO, DO NOT DISCLOSE THIS INFORMATION * _____________________________________________________________

4.        I understand that the information used or disclosed may be subject to re-disclosure by the person or class of persons or facility receiving it, and would then no longer be protected by federal privacy regulations.

5.        I may revoke this authorization by notifying _______________________________ in writing of my desire to revoke it.  However, I understand that any action already taken in reliance on this authorization cannot be reversed, and my revocation will not affect those actions.

6.        My purpose/use of the information is for ___________________________________________________________________________ .

7.        This authorization expires on _____________, 200___, OR upon occurrence of the following event that relates to me or to the purpose of the intended use or disclosure of information about me:  _____________________________________.

FEES FOR COPIES:  Federal and state laws permit a fee to be charged for the copying of patient records.  You may be required to pre-pay for the copies; if not, then your copies will be mailed along with an invoice.

 

THIS FORM MUST BE FULLY COMPLETED BEFORE SIGNING – note that signature is required in two places.*

___________________________________________

_______________________________

___________________________________

Signature of Individual*
(The person about whom the information relates)

Date of Individual’s Signature

Date of Birth or
Social Security Number

OR, if applicable –

_______________________________________

_______________________________

___________________________________

Signature of Guardian* or
Personal Representative of Patient’s Estate

Date of Guardian’s/Personal Representative’s Signature

Description of Authority to Act
for the Individual

A copy of this completed, signed and dated form must be given to the Individual or other signatory.

Official Use Only

 

 

 

 

 

 

 

 

Received

 

Processed By

 

Log #