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

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).
Patient Name
Patient Date of Birth

MonthDayYear
Date
Patient Street Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Phone
Cell/Alternate #
REQUEST AUTHORIZATION: I hereby authorize Morgan Medical Center (MMC)/Morgan Physician Services (MPS) to receive records (PHI) from the facilities or HIE checked below.

	Provider/Physician Office	Phone	Fax
Provider 1
Provider 2

Commonwell Health Information Exchange (HIE): This allows MMC to access my medical records for my safety & care, including allergies, medications, diagnostic results. This will allow MMC staff to provide you with the most accurate medical treatment
DISCLOSURE: Records to be disclosed to the person or entity listed below by

MailSecure Email PortalPick UpFax
Name
Address

Street Address

Street Address Line 2

City/State/ZipState / Province

Postal / Zip Code
Email
example@example.com
Phone
Fax
Purpose (Describe)
Purpose

Patient/Representative RequestOther
DESCRIPTION OF INFORMATION FOR RELEASE:

Entire Medical RecordEmergency Room RecordLab ReportsFinancial Record/Itemized StatementAbstract of Record*Radiology CDRadiology ReportsMammogram ReportOther
*An Abstract of the record includes the History/Physical Report, Operative, Consultation & Discharge Summary Reports and diagnostic testing.
Applicable Dates of Service

MonthDayYear
Date
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.
Patient or Legal Representative*
Please PRINT name
Today's Date

MonthDayYear
Date
Time
*As a Legal Representative, my relationship to the patient is:
Any document providing such authority must be on file with MMC.
Any document providing such authority must be attached or on file with MMC.

Cancelof
Upload a copy of your Driver's License to verify your identity:

Cancelof
For Office Use Only:
Prepared By
Date Filled

MonthDayYear
Date
Identification Verified by MMC Staff
MRN/FIN (to be completed by MMC staff 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
Should be Empty: