Request for Authorization for Disclosure of Health Information

Request for Authorization for Disclosure of Health Information

Clarinda Regional Health Center
Patient Information:
Name*

First NameLast Name
DOB *

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Release Information From:
Person and/or Place:*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Fax:
Release Information To:
Person and/or Place:*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Fax:
Purpose for release of records:*

Continuing CareChanging PhysicianMovingPersonalDischarged SummaryInsuranceMilitarySchool
Information to be released:*

AllDoctor's notesLabsX-Rays (reports and/or films)EKG'sOperative ReportERH&PDischarge SummaryHIV/AIDS TestingOther
Mental Health Records to be Released*

AllPsychiatric EvaluationPsychological Evaluation/TestingClinical Intake Evaluation/Progress NotesWritten Report Regarding TreatmentN/AOther
Date of Service:
Date to Date I authorize service dates
The following person has permission to pick up my medical records:*

First NameLast Name
Relationship*
Is there a second person you would like to grant permission to pick up your medical records?*

YesNo
Name*

First NameLast Name
Relationship*
I AUTHORIZE RELEASE OF ALL ALCOHOL AND/OR DRUG TREATMENT RECORDS THAT ARE PART OF THE RECORDS I SPECIFIED ABOVE UNLESS OTHERWISE INDICATED BELOW:
Do NOT release alcohol or drug treatment records protected under federal law.

Do not release these records
I may revoke this authorization at any time by sending written notice to the facility/provider releasing records. A revocation is not valid if (1) action was previously taken in reliance on this authorization, or (2) If this authorization was obtained as a condition for obtaining insurance coverage. I authorize the facility/provider to disclose medical information to the party identified in the “Release Information To” section. I understand this may include information regarding mental health, alcohol/drug use, and HIV treatment. I understand that once disclosed, information may be re-disclosed by the recipient and no longer protected. I understand this authorization is voluntary and that I may refuse to sign. Unless allowed by law, my refusal to sign will not affect my ability to obtain treatment, receive payment, or my eligibility for benefits.
This authorization expires one year from the date of my signature unless I specify a different event, purpose or alternative expiration date here: Date
Patient or Authorized Representative Signature*

Clear
Date*

MonthDayYear
Date
Did you sign as a Authorized Representative?*

YesNo, I am the patient
What is your relationship to the patient?*
Date of Completion*

MonthDayYear
Date
Should be Empty:

Request for Authorization for Disclosure of Health Information

Patient Information:

Release Information From:

Release Information To: