Patient Authorization To Release Protected Health Information printable pdf download

PATIENT AUTHORIZATION TO RELEASE

PROTECTED HEALTH INFORMATION

*(Complete in full. See reverse side for important information.)

(name of patient)

(birthdate)

(

)

(street address)

(city, state, zip code)

(Phone number)

I authorize the use and/or release of my protected health information as described in paragraph 4 below. I

understand this authorization is voluntary and is made to confirm my instructions.

I understand that the information used or released as a result of this Authorization may no longer be protected by

federal privacy laws and may be further used or released by persons or organizations receiving it without obtaining

my authorization.

AUTHORIZE by DROPPING FORM OFF AT ANY

TO RELEASE PROTECTED HEALTH INFORMATION TO:

DEAN CLINIC PHARMACY or MAILING FORM

Name

to:

Dean Clinic – Pharmacy Administration

Address

2901 West Beltline Highway , Suite 300

City/State/Zip

Madison, WI 53713

Any Questions call: (608) 250-1400

HEALTH INFORMATION TO BE RELEASED:

Dean Pharmacy Prescription Records

5. TODAY’S RECORD REQUEST is for the FOLLOWING DATE(S):

AFTER TODAY, it is my intention to authorize the release of records generated before, on, or after the date of my

signature on this authorization. Records may be requested from any Dean Clinic Pharmacy or Dean Clinic -

Pharmacy Administration for a period of 2 years from the date this form was signed.

PURPOSE OR NEED FOR DISCLOSURE: (Check applicable categories)

further medical care

at the request of the patient

legal investigation

insurance eligibility/benefits

vocational rehabilitation evaluation

disability determination

Other

SIGNATURE:

I have had full opportunity to read and consider the contents of this Authorization, and I confirm that the

contents are consistent with my direction to the health care provider. I understand that, by signing this form,

I am confirming my authorization that the health care provider may use and/or disclose to the persons and/or

organizations named in this form the protected health information described in this form.

Signature:

Date:

If this Authorization is signed by a representative on behalf of the patient, complete the following (see reverse side for details):

Representative’s Name:

Relationship to Patient:

YOU ARE ENTITLED TO A COPY OF THIS AUTHORIZATION AFTER YOU SIGN IT.

SEE REVERSE SIDE FOR IMPORTANT INFORMATION

A9001024 (8/10)

Patient Authorization To Release Protected Health Information

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