Release Authorization (Bloomington 2022)

Release Authorization

A signed and dated Release Authorization is required for all new patients. This will allow us to obtain necessary medical records so that your new care provider can get familiar with your recent medical history before your first appointment.
Patient's Name*

First NameLast Name
Date of Birth*
Last 4 of SSN#*
Authorization Type

By signing this form you authorize Centerstone Health Services to obtain medical record information from:
*

Centerstone of IndianaOther
Name of Other Provider or Hospital*
Address of Doctor or Hospital

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number of Doctor or Hospital
Please enter a valid phone number.
Fax Number of Doctor or Hospital
Please enter a valid phone number.
Purpose

The requested medical in formation is to be used for "Continuation of Care."

Type of Information

By signing this form you authorize Centerstone Health Services to obtain your entire medical record.

All Centerstone of Indiana release requests are for the last three office notes and lab results within the last 12 months.

Release Dates

All treatment dates.

Exclusions
Indicate specific information to be EXCLUDED from this authorization, if any: (Check all that apply)

Mental HealthGenetic InformationDrug & AlcoholHIV/AIDSInfectious Disease
Authorization

I understand that I have the right to inspect or copy the health information I have authorized to be used or disclosed by this authorization form. I may arrange to inspect my health information or obtain copies/electronic media of my health information. I understand that the person(s) and /or organizations(s) listed above whom I am authorizing to use and /or disclose my information may not condition treatment, payment, enrollment in a health plan or eligibility for health care benefits on my decision to sign this authorization. Revocation Process: I understand that I may by placing my request in writing to the Centerstone Health Services revoke this authorization at any time except to the extent that action has been taken in reliance on it and that in any event this authorization will expire one year from the date of my signature or as otherwise specified by date, event or condition as follows. Photocopy: I further authorized that a photocopy of this authorization form will be fully acceptable as an original and that Centerstone Health, may deny the release of protected health information, if it has reason to believe this authorization has been altered or is not a true and accurate authorization initiated by the patient. Fees for copies: Federal and state laws permit a fee to be charged for the copying of patient records. You may be required to prepay for the copies; if not, then your copies will be mailed along with an invoice. I voluntarily authorize the use or disclosure of my protected health information to Requestor, either verbally, in writing, and/or facsimile, as described above.
Signature*

Clear
Date*

MonthDayYear
Date
Please verify that you are human*
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