Authorization For The Release And/or Discussion Of Protected Health Information

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Authorization for the Release and/or Discussion of Protected Health
Information
Patient Name:__________________________ SS#: ______-_____-______Birth Date: ___/____/_____
Authorization
1.
I, ________________________________________, hereby authorize
(Name of Patient or Patient’s Legally Authorized Representative)
2.
Name of person or
organization:____________________________________________________
Street Address: ______________________________________________________________
City, state, zip:_____________________________
Telephone: (
)
3. A.
To release and/or discuss the following information
Complete Record
Outpatient Care
Inpatient Care
X-Ray Results
Laboratory Results
Treatment Plan Update
Other
_________________________________________________________________
If my record contains the following information, it is also released if CHECKED in boxes below:
Substance Abuse
Mental Health Treatment
HIV Testing or
Treatment
4.
To ________________________________of
{name, address and phone of organization]
This information release is at my request for the purpose of legal assistance.
5 Signature:
I have carefully read and understand the above information, and do herein consent to its
disclosure. I am aware that information regarding my medical condition will be released to those
persons or agencies named above. I understand that, if the person(s) or organization(s) that I
authorize to receive my protected health information are not subject to federal and state health
information privacy laws, subsequent disclosure by such person(s) or organization(s) may not be
protected by those laws.
I understand that this consent is subject to revocation, in writing, at any time, unless
action based on it has already begun.
This authorization expires _____6 months _____one year from today’s date, or upon the
following specified event:
____________________________________________________.
I authorize the use of a copy of this form for the disclosure of the information described above.
Signed __________________
Relationship__________________ Date: ____/____/____

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