Authorization Form For Release Of Health Information Form - 2011
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1AUTHORIZATION FORM FOR RELEASE OF HEALTH INFORMATION
PATIENT NAME: ________________________________________________________________________________________
LAST
FIRST
MI
MAIDEN OR OTHER NAME
DATE OF BIRTH: _____-_____-_____ SS#: _____-_____-_____ MEDICAL RECORD #: ____________________________
MO
DAY
YR
ADDRESS: _______________________________________ CITY: ______________________STATE: ____ZIP: __________
DAY PHONE: _________________________EVENING PHONE:
I HEREBY AUTHORIZE PP OF THE SOUTHERN FINGER LAKES:
TO RELEASE
TO OBTAIN
MY HEALTH INFORMATION TO/FROM:
NAME: ________________________________________________________________________________________________
ADDRESS: _______________________________________ CITY: ______________________STATE: ____ZIP: __________
PHONE: ____________________________________________ FAX: ______________________________________________
HEALTH INFORMATION TO BE RELEASED:
I specifically authorize release of the following information:
DATES
Most recent annual exam
_____________________
All visits since: (fill in date)
_____________________
Pap Smear
_____________________
Lab reports
_____________________
Progress notes
_____________________
Abortion Record
_____________________
Follow Up Care related to Medical Abortion of
_____________________
Follow Up Care related to Surgical Abortion of
_____________________
Other: __________________________________
_____________________
Entire Medical Record
(Fee of $.50/page. Please allow 10 days. We cannot refuse to give you a copy due to inability to pay)
PURPOSE OF RELEASE OF INFORMATION:
At my request
Continuity of care
Other: ___________
To ensure that our records are current and accurate, please complete & return this form promptly to the clinic site checked
below. This will enable us to provide our client with proper medical care. Thank you for your cooperation.
Corning
Elmira
Hornell
Ithaca
Watkins Glen
th
135 Walnut St.
755 E. Church St.
111 Seneca St.
620 W Seneca St.
106 W. 4
St.
(607)962-4686
(607)734-3313
(607)324-1124
(607)273-1513
(607)535-0030
(607)962-7520 fax
(607)734-3392 fax
(607)324-2666 fax
(607)273-8776 fax
(607)535-5040 fax
CONDITIONS OF AUTHORIZATION
1.
This Authorization will expire on (insert date or event):
2.
I may revoke this Authorization at any time by notifying PP of the Southern Finger Lakes in writing, and it will be effective on
the date notified except to the extent that PP of the Southern Finger Lakes has already acted upon such Authorization.
3.
Information used or disclosed pursuant to this Authorization may be subject to re-disclosure by the recipient and no longer
protected by Federal privacy regulations.
4.
By authorizing this release of information, my healthcare and payment for my healthcare will not be affected if I do not sign this
Authorization form.
I have been offered a copy of this signed Authorization form.
5.
____________________________________ __________ (OR) _______________________________________________ _________
SIGNATURE OF PATIENT
DATE
PARENT/LEGAL GUARDIAN/AUTHORIZED PERSON
DATE
______________________________________________________________
WITNESS
DATE
AUTHORITY TO ACT ON BEHALF OF PATIENT
FOR OFFICE USE ONLY
DATE REQUEST FILLED: _________________________________
BY: ____________________________________________________
IDENTIFICATION PRESENTED: ___________________________
FORM OF IDENTIFICATION: _____________________________
Y:\PTServices\PPSFL\CONSENTS\Record Release 4.27.11.doc
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