Authorization Release of Information & for Use/Disclosure of Protected Health Information (PHI)

PATIENT INFORMATION: The following information is needed to assist the provider in locating the patient’s medical record(s).

REQUEST AUTHORIZATION: I hereby authorize Morgan Medical Center (MMC)/Morgan Physician Services (MPS) to receive records (PHI) from the facilities or HIE checked below.

*An Abstract of the record includes the History/Physical Report, Operative, Consultation & Discharge Summary Reports and diagnostic testing.

Authorization for Use/Disclosure of Protected Health Information

I understand the information that I am authorizing the above Morgan Medical Center providers to use/disclose may include information related to diagnosis or treatment of mental illness, substance abuse, chemical dependency, and alcohol abuse, including privileged psychiatric or psychological communications and other detailed mental health information; infectious diseases, such as HIV/AIDS, venereal disease, tuberculosis or hepatitis; and genetictestingor information derived from genetic testing. I hereby waive and privilege concerning such information for the disclosure to the orentityIhave authorized above. I understand the information used/disclosed pursuant to this authorization will not include psychotherapy person notes which are notes recorded by a mental health professional documenting or analyzing contents of conversation during counseling sessions that are kept separate from the rest of the medical record.

I understand that information used or disclosed pursuant to the authorization may be subject to re-disclosure by the recipient of the information and may then no longer be protected by federal privacy regulations.

I understand that unless otherwise limited by state or federal regulations, I may revoke this authorization at any time by presenting my revocation in writing to MMC/MPS Attention Privacy Officer, P. O. Box 860, Madison, GA 30650, except to the extent that such entity has acted in reliance of this authorization.

I understand that this authorization is specific to the information, purpose and date(s) of service indicated above. I further understand that authorization is valid for 90 days from today's date and will expire at that time unless another date is written here.

Note: There may be fees for provision of the information requested; however, records for treatment purposes may be faxed to the patient's healthcare provider when requested at no charge. Under most circumstances, applicable laws permit up to thirty (30) days for record requests to be processed.

For Office Use Only:

Morgan Medical Center/HIM Office
Mailing Address: P. O. Box 860, Madison, GA 30650
Fax: 706-752-2288
Phone: 706-752-2243
Email: HIMMailingGroup@mmh.org