Release of Medical Information (working)

Release of Medical Information
Release of Medical Information
Patient's Legal Name: *

First Name Last Name
Date of Birth *

Month Day Year
Date
Phone Number *
Please enter a valid phone number.
Which practice/location of care would you like to go to? *

Families First Health & Support Center, 8 Greenleaf Woods Drive, Portsmouth, NH Goodwin Community Health, 311 Route 108, Somersworth, NH Lilac City Pediatrics, 180 Farmington Rd., Rochester, NH (pediatric ONLY)
I authorize Greater Seacoast Community Health to *

Release the patient's personal health information to the facility or person named below Obtain the patient's personal health information from the facility or person named below
Facility/practice where records currently are: *
Phone # *
Fax #
Address *
City, State, Zip *
Email
example@example.com
For dates of care from:

Month Day Year
Date
To:

Month Day Year
Date
Please INITIAL all types of information that you authorize us to release or obtain:
Medical diagnostic, testing, and treatment information
Dental diagnostic, testing and treatment information and /or x‐rays taken
Records of immunizations and physicals
Current prenatal records, copies of all lab tests (including HIV results) and/or scans
Summary of labor and delivery notes for the following date of delivery
Date of delivery

Month Day Year
Date
Information about sexually transmitted diseases and/or HIV/AIDS
Psychiatric/psychological evaluation(s), reports, assessments, summaries, psychotherapy notes or other documents with diagnosis, prognoses, recommendations, or testing records and behavioral observations
Drug and alcohol information including evaluation, diagnostic, treatment and progress notes.
Other:
Type what information that you authorize us to release or obtain:
Methods of Disclosure Authorized: Faxed, written, phone conversation, in-person and/or secure e-mail.
- I understand that I may revoke (withdraw) this authorization at any time by notifying the practice in writing. Revocation will be effective as of date received.
- I understand that a revocation will not apply to: 1)any actions that this practice has already taken while relying on this authorization before I revoke it; or 2) if this authorization was obtained as a condition of obtaining insurance coverage and the insurer has a legal right
- I understand that I might be denied services if I refuse to consent to disclosure for purposes of treatment, payment, or health care operations , if permitted by state law. I will not be denied services if I refuse to consent to disclosure for other purposes.
- I understand that the recipient of some information disclosed under this authorization may re-disclose this information and that the information will no longer be protected by federal privacy regulations.
- I understand that I have the right to: 1) Inspect or copy the protected heath information to be used or disclosed as permitted under Federal law; 2) Refuse to sign this authorization.
- This authorization will remain in effect for one year and may be revoked at any time by notifying this practice in writing.
- Unless otherwise noted, only the past two years of electronic records as stipulated above will be sent.
Signature of Patient and/or Legal Representative Signature of Patient and/or Legal Representative (please make it as big as box size) NOTE: INITIAL OR NON LEGAL SIGNATURE WILL BE DENIED *

Clear
Date *

Month Day Year
Date
Should be Empty: