360infusioncenter.com - AUTHORIZATION TO USE OR DISCLOSE MEDICAL RECORDS

AUTHORIZATION TO USE OR DISCLOSE MEDICAL RECORDS
I give authorization to the provider listed below to disclose a copy of the specific health/medical information identified below:
NAME OF PATIENT
DOB

MonthDayYear
Date
SS# last four:
TO: (Name, Address, Phone of Recipient of Records)

Name: 360 Infusion Center
Phone: 352-549-9962
Address:14107 Cortez Blvd. Brooksville, FLORIDA 34613
RECORDS FROM (Who is Releasing the Records):
Name
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
By Checking the Boxes Below, I Specifically Authorize the Use and/or Disclosure of the Following

Health Information and/or Medical Records, If Such Information and/or Records Exist:
Please send the entire Medical Record (all information) to the above named recipient.

Office Notes and ReportsMost recent one year historyMost recent three-year historyRx HistoryTranscribed hospital reportsLaboratory reportsBilling StatementsDiagnostic ReportsDiagnostic Films
Others List Here
For dates:
From

MonthDayYear
Date
To

MonthDayYear
Date
The Following Items Must Be Initialed to Be Included in the Use And/or Disclosure:
Initial I understand that a complete copy of my medical records may include confidential information such as mental health, alcohol and/or drug abuse, HIV and other STD results. I also understand that if I want this information excluded from the copies, I must indicate this in writing.
Initial Drug/Alcohol diagnosis, treatment or referral information (Federal regulations require a description of how much and what kind of information is to be disclosed.) Describe below:
Describe:
I understand that, if the person or entity receiving the information is not a health care provider or health plan covered by federal privacy regulations, the information described above may be re-disclosed and no longer protected by HIPAA and other federal and state regulations. However, the recipient may be prohibited from disclosing substance abuse information under the Federal Substance Abuse Confidentiality Requirements.
I also understand that the person I am authorizing to use and/or disclose the information may not receive compensation for doing so.
I further understand that I may refuse to sign this authorization and that my refusal to sign will not affect my ability to obtain treatment or payment of my eligibility for benefits. I may inspect or copy any information to be used and/or disclosed under this authorization.
Finally, I understand that I may revoke this authorization, in writing, at any time, provided that I do so in writing, except to the extent that action has been taken in reliance upon this authorization. Unless Revoked Earlier, this Authorization Will Expire in Six (6) Months from the Date of Signing or until
Insert Date
Patient Name (Print):
Signature

Clear
Date

MonthDayYear
Date
Legal Guardian Name:
Legal Rep. Signature:

Clear
STANDING AUTHORIZATION FOR DISCLOSURE OF INFORMATIONSTANDING AUTHORIZATION FOR DISCLOSURE OF INFORMATION
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) restricts the use or disclosure of protected health information (PHI) other than treatment, payment or healthcare operations (TPO). Others that are permitted to receive disclosure of information by law include: Judicial proceedings, coroners, medical examiners, research purposes, law enforcement, worker’s compensation and other areas so designated by law.

Release or disclosure of information to family members, friends, clergy or others involved in a patient’s care is NOT included in the General Rule and require specific authorization for disclosure of information.

If you would like us to share your PHI with family members or others, please fill in the information below for each individual, designate if unrestricted or limited release of information and date and initial each authorization. Please note that ABSOLUTELY NO INFORMATION WILL BE DISCLOSED to spouses, children, other family members, care givers or friends if not authorized below. You may rescind or change any authorization by a written request at any time.

1. Please list the family members or other person(s), if any, whom we may inform about your general medical condition and your diagnosis, records, reports (including treatment, payment and health care operations):

	Name	Relationship	Phone	All Access	Appointments	Lab results
1
2
3
4
5

2. Please list the family members or others, if any, whom we may inform about your medical condition ONLY IN AN EMERGENCY.

	Name:	Relation:	Phone:
1
2

3. Please print the address of where you would like your billing statements and/or correspondence from our office to be sent if other than your home. (Confidential Communications):
4. Print the telephone number or email address where you want to receive calls about your appointments, lab and x-ray results or other health care information if other than your home.
Phone Number
Please enter a valid phone number.
Email
example@example.com
5. Can confidential messages (i.e., appointment reminders) be left on your telephone answering machine or Voice Mail?

YesNo
I understand the Privacy Protection Act and have been offered a copy of the Notice of Privacy Policies and do hereby authorize to disclose as I have identified above.
Patient Name:
Date

MonthDayYear
Date
Patient Signature:

Clear
Legal Guardian/Representative Name:
Legal Rep Signature:

Clear
Should be Empty:

AUTHORIZATION TO USE OR DISCLOSE MEDICAL RECORDS

STANDING AUTHORIZATION FOR DISCLOSURE OF INFORMATIONSTANDING AUTHORIZATION FOR DISCLOSURE OF INFORMATION