Authorization For The Use And Disclosure Of Protected Health Information Form

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A UTHORIZATION FOR THE USE AND DISCLOSURE OF
PROTECTED HEALTH INFORMATION
________________________________________________ hereby authorizes the use or disclosure of the individually
Print Patient/Legal Representative or Parent/Legal Guardian Name
Identifiable health information of ____________________________________________________ as described herein.
Print Patient Name
Date of Birth
Person/organization authorized to use/disclose the information: Person/organization authorized to receive the information:
Name/organization __________________________________
Name/organization ______________________________
Address ___________________________________________
Address _______________________________________
City, State, Zip ______________________________________
City, State, Zip __________________________________
Phone ___________________ Fax _____________________
Phone ___________________ Fax _________________
For the purpose of:
Legal Request
Moving out of Area
New Local Physician
Other (please specify)
___________________________________________________________________________________________________
This authorization will expire on the following date, event or condition: ________________________________________________
If I fail to specify an expiration event or condition, the authorization will expire in one year. I understand that this aut horization
is revocable upon written notice to the office where the original authorization is retained, except to the extent that action has
already been taken on this authorization. Mental health, alcohol, drug, HIV and/or AIDS information is confidentially protected by
Federal and state law which prohibits disclosure without specific written authorization of the undersigned, or as otherwise permitted by
such regulations.
I further request that no genetic counseling/testing information in my record be released without my written
authorization, except as otherwise required by law. I understand that I may select the information from the list below to be released
by placing my initials in the space provided. Furthermore, I understand that any disclosure of information from my records
carries with it the potential for an unauthorized re-disclosure of my health information. I further understand that Physician
Associates, LLC may not condition the provision of treatment, payment, enrollment in the health plan, or eligibility for benefits on the
provision of this authorization.
Date(s) of Service: From: __________________________________
To: _____________________________________
Place your INITIALS by each item to be released or reviewed:
____ Abstract of Record
____ All diagnostic test results
____ Pathology/Operative Report(s)
____ Radiology only
____ Consultation/Progress Note(s)
____ Lab only
____ Complete Record (charges may apply)
____ Other (specify) _____________________
In addition, place your INITIALS by each specific item: (if applicable)
____ Mental Health
____ HIV Testing
____ Genetic Counseling/Testing Information
____ Drug and/or Alcohol
____ AIDS Information
____ STD/Communicable Diseases
_______________________________________________________________
________________________
Patient/Legal Representative or Parent/Legal Guardian Signature Required
Date of Authorization
_________________
__________________________________
_______________________________
Patient Date of Birth
Social Security Number (optional)
Identification Shown
_________________________________________________________
_______________________________
Translator or Interpreter’s Name
Telephone Number
____________________________________________________________________________________________________________________________
Address
City
State
Zip Code
Official Use Only: ____________________________________________________________________________________
Name of Person Releasing Information
Date
HIM 12.01.B.17

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