Authorization for Release of Health Information

Patient Name:

Date of Birth:

Social Security Number:

Patient Address:

City:

State:

Zip:

I, or my authorized representative, request that health information regarding my care and treatment be released as set forth on this form: In accordance with VA State Law and the Privacy Rule of the Health Insurance Portability and Accountability Act of 1996 (HIPAA), I understand that:

SHENANDOAH PAIN AND PALLIATIVE CARE CLINIC, LLC uses SureScripts, Inc., a prescription system that allows prescriptions and related information to be exchanged between my providers and the pharmacy. The information sent between these systems may include details of any and all prescription drugs I am currently taking and/or have taken in the past. This information will be utilized by SHENANDOAH PAIN AND PALLIATIVE CARE CLINIC, LLC.
This authorization may include disclosure of prescription information related to alcohol and drug abuse, mental health treatment, and/or confidential HIV related information by SureScripts, Inc. to SHENANDOAH PAIN AND PALLIATIVE CARE CLINIC, LLC.
I have the right to revoke this authorization at any time by writing to SHENANDOAH PAIN AND PALLIATIVE CARE CLINIC, LLC. I understand that I may revoke this authorization except to the extent that action has already been taken based on this authorization.
Signing this authorization is voluntary. My treatment, payment, enrollment in a health plan, or eligibility for benefits will not be conditioned upon my authorization of this disclosure.
Information disclosed under this authorization might be re-disclosed by the recipient, and this re-disclosure may no longer be protected by state or federal law.
This authorization expires one year from the date of my signature below.
THIS AUTHORIZATION DOES NOT AUTHORIZE SHENANDOAH PAIN AND PALLIATIVE CARE CLINIC, LLC TO DISCUSS MY HEALTH INFORMATION OR MEDICAL CARE WITH ANYONE OTHER THAN THOSE PERMITTED UNDER APPLICABLE LAW.

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.

Name / Signature of patient or representative authorized by law:

Date:

Relationship to Patient:

Interpreter, if utilized:

Witness Name / Signature:

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