Authorization For Release And Disclosure, And/or Request For Medical Information And Records printable pdf download

AUTHORIZATION FOR RELEASE AND DISCLOSURE,

AND/OR REQUEST FOR MEDICAL INFORMATION AND RECORDS

I,_______________________________________________(patient), (____________date of birth) authorize Pine Rest

Christian Mental Health Services to: (√ one or both below, or form is invalid)

_____

release information from my medical records to the individual/organization listed below

_____

request information from the individual/organization listed below

Name: ________________________________________________________________________________

Address: ______________________________________________________________________________

For the following purpose, use, or need: ___________________________________________________________________

____________________________________________________________________________________________________

The following information from my psychiatric/medical records may be disclosed, covering the dates from ___________ to

___________:

□ Treatment Summary

□ Psychiatric Evaluation

□ Psychological Testing

□ Physical Exam

□ Laboratory Studies

□ Initial Assessment

□ Exchange of all written and verbal health information pertinent to the coordination of my care and treatment

□ Other _____________________________________________________________________________________________

□ Exclude the following information: _______________________________________________________________________

I acknowledge such information cannot be disclosed without my written informed consent unless otherwise provided by law. I

further understand that such information to be disclosed may include treatment of Psychiatric, Substance Abuse, and

HIV/AIDS related illnesses. I agree that the information may be faxed for expediency. I have the right to revoke this

authorization at any time. Any revocation will be done in writing to the attention of the Medical Records Director and any

information previously authorized and released will not be subject to revocation. I acknowledge and authorize that the

information indicated on this form will be sent to the individual listed above. The Health Insurance Portability and Accountability

Act of 1996 (HIPAA) protects the privacy of health information. Persons or organizations receiving this health information may

not be bound by the provisions of this law. However, re-disclosure of this information is prohibited by the Michigan Mental

Health Code (sections 748, 749 and 750 of the Public Act 258 of 1974 as amended) and also by Title 42 of the Code of

Federal Regulations, Part II, with which this authorization complies. The released information may not be copied, shared or re-

released, except as consistent with the authorized purpose stated above. I understand that I am not required to sign this

authorization, and that Pine Rest will not refuse me treatment if I refuse to sign. I have the right to inspect and obtain a copy of

the information disclosed. A true and exact photocopy/faxed copy of this authorization shall have the same effect as the

original.

If no expressed revocation is issued, this authorization will expire one year from the date indicated after my signature or upon

the following date, event or condition:

____________________________________________________________________________________________________

I have also had the opportunity to have this form explained to me and have my questions answered.

____________________________________ ______

__________________________________ _________

Patient/Parent/Guardian/

Date

Witness Signature

Date

Personal Representative Signature

Copy of this authorization provided: Yes______

Declined ______

Main Campus address: 300 – 68

Street, SE, PO Box 165, Grand Rapids, MI 49501-0165 (Phone 616-455-5000)

07-29-21970PR rev 04/03

Authorization For Release And Disclosure, And/or Request For Medical Information And Records

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