Release Authorization (Bloomington)
A signed and dated Release Authorization is required for all new patients. This will allow us to obtain necessary medical records so that your new care provider can get familiar with your recent medical history before your first appointment.
Patient's Name
*
First Name
Last Name
Date of Birth
*
Last 4 of SSN#
*
Authorization type
By signing this form you authorize Centerstone Health Services to obtain medical record information from:
Provider
IU Health
Centerstone
Name of Other Provider or Hospital
*
First Name
Last Name
Address of Doctor or Hospital
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number of Doctor or Hospital
-
Area Code
Phone Number
Fax Number of Doctor or Hospital
-
Area Code
Phone Number
Purpose
The requested medical in formation is to be used for "Continuation of Care."
Type of Information
By signing this form you authorize Centerstone Health Services to obtain your entire medical record.
Release Dates
All treatment dates
Exclusions
Indicate specific information to be EXCLUDED from this authorization, if any: (Check all that apply)
Mental Health
Genetic Information
Drug & Alcohol
HIV/AIDS
Infectious Disease
Authorization
I understand that I have the right to inspect or copy the health information I have authorized to be used or disclosed by this authorization form. I may arrange toinspect my health information or obtain copies/electronic media of my health information.I understand that the person(s) and /or organizations(s) listed above whom I am authorizing to use and /or disclose my information may not conditiontreatment, payment, enrollment in a health plan or eligibility for health care benefits on my decision to sign this authorization. Revocation Process: I understandthat I may by placing my request in writing to the Centerstone Health Services revoke this authorization at any time except to the extent that action has beentaken in reliance on it and that in any event this authorization will expire three months from the date of my signature or as otherwise specified by date, event orcondition as follows. Photocopy: I further authorized that a photocopy of this authorization form will be fully acceptable as an original and that CenterstoneHealth, may deny the release of protected health information, if it has reason to believe this authorization has been altered or is not a true and accurateauthorization initiated by the patient. Fees for copies: Federal and state laws permit a fee to be charged for the copying of patient records. You may be requiredto prepay for the copies; if not, then your copies will be mailed along with an invoice.I voluntarily authorize the use or disclosure of my protected health information to Requestor, either verbally, in writing, and/or facsimile, as described above.
Signature
*
Clear
Date
*
-
Month
-
Day
Year
Date
Please verify that you are human
*
Submit
Should be Empty: