Authorization to Disclose Medical Information

Authorization to Disclose Medical Information

ALL SECTIONS BELOW MUST BE COMPLETED FOR PROCESSING
Name*

First NameLast Name
Relationship to Patient*
Maiden or Former Name
Date of Birth*
Patient Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
DISCLOSE MEDICAL RECORDS

I hereby authorize Atkinson Family Practice to disclose my health information to:
New Physician/Practice:*
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Fax Number
Please enter a valid phone number.
Purpose of this Dislosure:*

TransferContinuity of Care (not leaving practice)LegalInsuranceConsult AppointmentPersonalOther
If you are transferring out of AFP, please tell us why:
Medical Information to be disclosed:*

All RecordsConsultationsDiagnostic Tests (labs, x-rays, EKG, colonoscopy, etc)Hospital NotesProgress NotesImmunizationsOther
Authorization covers:*

Past Three YearsEntire Period of CareSpecific Dates
Entire Period of Care starting (month & year)
Specific Dates (From: /To:)
Release of sensitive, protected information related to testing, diagnosis and/or treatment for HIV/AIDS, sexually transmitted diseases, drug/alcohol use/treatment and/or mental health/psychiatry is authorized only through express consent.

INDICATE THE AREAS YOU AUTHORIZE BY INITIALING EACH ONE BELOW. (AUTHORIZATION IS NOT VALID UNLESS INITIALED):
HIV/AIDS
Sexually Transmitted Disease
Mental Health/Psychiatry
Drugs/Alcohol
This authorization will expire one year from date of signature.
I understand that I may revoke this authorization at any time by making a written request to Atkinson Family Practice. I understand that actions taken in reliance on this authorization prior to revocations may not be reversible. I understand that Atkinson Family practice may not condition treatment, payment, enrollment or eligibility for benefits on my signing this authorization. State law prohibits re-disclosure without written authorization.
I acknowledge that I have signed this Authorization voluntarily:
Signature of Patient/Authorized Representative

Clear
Print Name of Patient/Authorized Representative*
Date

MonthDayYear
Date