Authorization To Release Or Obtain Health Information Form - Louisiana Department Of Health And Hospitals
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2Louisiana Department of Health and Hospitals
Authorization to Release or Obtain Health Information
(including paper, oral and electronic information)
Name:
Request Date:
Mailing Address:
Date of Birth:
City/State/Zip:
Medicaid # or Social Security #:
I authorize:
Name: _____________________________________________________________________________________
Mailing Address: ____________________________________________________________________________
City, State, Zip Code: ________________________________________________________________________
Relationship: _______________________________
Telephone Number:_____________________________
RELEASE Information TO
or
OBTAIN Information FROM
(Place an “X” in the box that indicates if the information is being released OR requested.)
Name: _____________________________________________________________________________________
Mailing Address: ____________________________________________________________________________
City, State, Zip Code: ________________________________________________________________________
Relationship: _______________________________
Telephone Number:_____________________________
(Place an “X” in the box(es) that apply.)
The Purpose of this Authorization is indicated in the box(es) below.
Further Medical Care
Personal
Legal Investigation or Action
Changing Physicians
Research related treatment
Creating health information for disclosure to a third party.
Other: (Specify)_________________________________________________________________________
I authorize the release of the following protected health information
.
(Place an “X”in the box(es) that apply to the information you want released or you want to obtain.)
Entire Record
Medical History, Examination, Reports Surgical Reports Treatment or Tests
Prescriptions
Immunizations Hospital Records including Reports Laboratory Reports
X-ray Reports MR/DD Records Other: ___________________________________________________
In compliance with state and/or federal laws which require special permission to release otherwise privileged
information, please release the following records.
Alcoholism
Drug Abuse
Mental Health
Vocational Rehabilitation
HIV (AIDS)
Sexually Transmitted Diseases
Genetics
Psychotherapy Notes
Other___________________________________________________________________________________
This authorization shall expire on _____________________________ (date or event) and is
needed for the period beginning _____________ and ending _____________.
I understand that if I do not specify an expiration date, this authorization will expire six (6) months from the date
on which it was signed. I acknowledge that I have read both pages 1 and 2 of this form. I authorize a copy
(including electronic or faxed copy) of this form for the disclosure of the information described above.
_____________________________
____________________________________________________________
Signature of Individual or Personal Representative authorized by law
Date
Please submit medical information to:
Agency Representative
Title
Date
Telephone
Fax
Email
HIPAA 402P
Issued 03/10
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Parent category: Legal