Authorization Form To Release Patient Medical Information
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1
2Authorization to Release Patient Medical Information
PATIENT INFORMATION:
Patient Name___________________________________________________ Chart # __________________
_
Former Name(if any)_____________________________________________ SS #_____________________
Daytime Phone #
DOB ____________________
________________________________________________________________________
INFORMATION TO BE RELEASED FROM:
I hearby authorize (Name of Organization)_____________________________________________________
to release the following medical information contained in the patient’s medical record.
Address________________________________________________________________________________
Street
City
State
Zip
INFORMATION TO BE RELEASED TO:
Name of Organization_____________________________________________________________________
Address________________________________________________________________________________
Street
City
State
Zip
Purpose or need for this information:_________________________________________________________
TYPE OF INFORMATION TO BE RELEASED
I. GENERAL RELEASE:
TYPE OF RECORD
DATES OF TREA TMENT
□ Medical Records
Excluding Protected Records From
to___________________
_____________
I
(this will be limited to 2 years of information including Lab, X-ray reports unless otherwise stated)
□ Lab results (specify)_______________________________ From _____________ to______________
□ X-Ray Reports (specify)____________________________From _____________ to _____________
□ Other Records (specify)_____________________________From _____________ to _____________
II. INFORMATION PROTECTED BY STATE
FEDERAL LAW:
I
□ Drug Abuse Diagnosis
Treatment*
From______________ to _____________
I
□ Alcoholism Diagnosis! Treatment*
From ______________ to _____________
□ Mental Diagnosis / Treatment**
From ______________ to _____________
_
(May include treatment In Pain Management and Center for Women’s Health or Psychiatry)
□ Sexually Transmitted Disease***
Diagnosis / Treatment or Counseling
From ______________ to _____________
_
(includes AIDS / HIV)
PATIENT AUTHORIZATION TO RELEASE MEDICAL INFORMATION
________________________________________
_________________________
Date
Signature of Patient
Legally Responsible Parts’
Relationship to Patient if not Patient
I
AUTHORIZATION VALID FOR 90 DAYS ONLY AND MAY BE REVOKED IN WRITING AT ANY TIME PRIOR
TO 90 DAYS BY NOTIFYING THE MEDICAL RECORD DEPARTMENT (TO BE VALID AUTHORIZATION
MUST BE SIGNED AND DATED. SEE BACK OF FORM FOR FURTHER INFORMATION)
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Parent category: Business