SSI Authorization for Release of Medical Information

SSI Authorization for Release of Medical Information
Name*

First NameLast Name
Date of Birth *

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Date
Phone Number
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The information you may release subject to this signed release form is as follows:

Complete RecordsProgress NotesLab ReportsDischarge SummaryRadiology Reports and CDOperative ReportsOther
Release my Protected Health Information to the following physician/person/facility/entity and /or those directly associated with my medical care:
Purpose of Disclosure:

Referral to SpecialistContinuing CareLegalInsuranceDisability DeterminationWorkers CompChange of Doctor/ProviderPersonal/Self
I hereby authorize disclosure of the health information for the above names patient. This authorization is valid for 12 months from the date of signature. I understand that I may cancel this request with written notification but that it will not affect any information released prior to notification or cancellation. I understand that the information used or disclosed may be subject to redisclosure by the person or class of persons or facility receiving it, and would then no longer be protected by federal regulations. I understand that the medical provider to whom this authorization is furnished may not condition its treatment of me on whether or not I sign the authorization. The form authorizes release of information in accordance with Health Insurance Portability and Accountability Act, 45 CFR Parts 160 and 164, 5 U.S.C. 5701 and 7332 that you specify.

Clear
Date

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Charges for records: .HIPAA rule 45 C.F.R. 164.52 (c) $2.00 cost-based fee for reviewing information access request, $0.20 per page cost-based fee for compiling and reproducing pages. For mailed request only: $0.01 per page mailing cost for paper and toner. $0.15 per envelope mailing cost. for patient only. Records will be processed in 7 to 10 working days.
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