Outgoing Release of Information Authorization

Patient Name*

First NameLast Name

Date of Birth*

Date

MRN

Other Name

Address*

Street Address

Apt #

CityState / Province

Postal / Zip Code

Email

example@example.com

Web Enable

Yes

Telephone Number*

Please enter a valid phone number.

I authorize Refuah Health Center to disclose, verbally, in writing or via the patient portal, individually identifiable health information about me, or the patient as listed above, to the following:

Please list any individuals and their address(es)*

Please list any Provider/Facility and its address(es)*

Specific Information Requested*

All Health InformationOther

For the following to be included, indicate the specific information to be disclosed and initial below.

Records from alcohol/drug treatment programs

Yes, include

Initials

Information to be Disclosed

Clinical records from mental health programs, including psychotherapy notes

Yes, include

Initials

Information to be Disclosed

Clinical records from mental health programs, excluding psychotherapy notes

Yes, include

Initials

Information to be Disclosed

HIV/AIDS-related Information

Yes, include

Initials

Information to be Disclosed

Periods covering:

From

Date

To

Date

Other, please specify:

Information is to be used for the purpose of:*

Continuing medical treatmentAttorneyInsuranceOther

Please check if information can be left on an answering machine:

Yes

Phone Number

Please enter a valid phone number.

Other Phone Number

Please enter a valid phone number.

This authorization shall expire 12 months from the date of the request. This authorization may be revoked by me at any time by a written or verbal notice to Refuah Health Center, except to the extent that Refuah Health Center has relied on the authorization. Refuah Health Center will not condition treatment, payment, enrollment or eligibility for benefits on whether I sign this authorization.

This authorization may include disclosure of information relating to Alcohol and Drug Treatment, Mental Health Treatment, and Confidential HIV/AIDS-related information only if I place my initials on the appropriate line above. In the event the health information includes any of these types of information, and I initial the line on the box above. I specifically authorize release of such information to the person(s) indicated above.

With Some exceptions, health information once disclosed may be re-disclosed by the recipient. If I am authorizing the release of HIV/AIDS-related, alcohol or drug treatment, or mental health information, the recipient is prohibited from re-disclosing such information or using the disclosed information for any other purpose without my authorization unless permitted to do so under federal or state law. If I experience discrimination because of the release or disclosure of HIV/AIDS-related information, I may contact the New York State Division of Human Rights at 1-888-392-3644. This agency is responsible for protecting my rights.

Patient Signature*

Or Legally Authorized Representative

Date*

Date

Relationship of Authorized Person