Authorization for Release of Health Information To Us

PATIENT NAME:

DOB:

ADDRESS:

MAIN PHONE:

ALT. PHONE:

I hereby authorize the release of the following records:

Immunization Records Only

Labs Only

Include Mental Health/Substance Abuse Records

Other

Please specify:

Checkbox

Records to exclude from this request - please check the appropriate areas not included in your request

Mental Health Records-including depression

Drug and/or Alcohol use/abuse

Other

If other, please specify:

FROM: Physician/Clinic Name:

Mailing Address:

City:

State:

Zip Code:

FAX #:

TO: Caring Hands Children’s Clinic, LLC
P. O. Box 1400
Monticello, MS 39654
601-587-4515 (fax)

I understand that:

This Authorization is valid for one year from date signed, unless I revoke/withdraw this Authorization in writing or unless an earlier date is specified here: __. I may revoke/withdraw this Authorization, except to the extent that action has been taken prior to receipt of the revocation/withdrawal, by mailing or faxing my written request the clinic or department where my Authorization was made or given. A photocopy is as valid as the original.
Once My Health Information is disclosed as requested, it may no longer be protected by federal and state privacy laws, and could be redisclosed by the person(s) receiving it.
The medical information released may contain information related to HIV status, AIDS, sexually transmitted diseases, mental health, drug and alcohol abuse, etc.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Signature of Patient if age 18 or older:

Date:

If you are NOT the patient but are signing on behalf of the patient, please complete below:

Name:

I am the:

Parent with Parental Rights Court Appointed Guardian (Must provide legal documentation)

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Representative’s Signature:

Date:

Relationship to Patient:

Your information will be encrypted.