PATIENT AUTHORIZATION FOR DISCLOSURE OF PROTECTED HEALTH INFORMATION

340 Court St Tupelo, MS 38804 phone 662-844-6272 fax 662-844-1603 www.tupelodermcenter.com 100 Norman Road Corinth, MS 38834 phone 662-205-4762

Patient Name:

Date of Birth:

Address:

City:

State:

Zip:

E-mail Address:

Phone:

I authorize the following organization to release information as stated below from the patient health information record:

INFORMATION TO BE RELEASED FROM:

Organization:

Street Address:

City:

State:

Zip:

Phone:

Fax:

INFORMATION TO BE RELEASED TO:

Organization:

Street Address:

City:

State:

Zip:

Phone:

Fax:

INFORMATION TO BE RELEASED

Dates of service for records requested:

Beginning:

Thru:

Discharge Summaries

Operative Reports

Radiology Reports

Lab/Pathology Report

Clinic Notes

Other

Other:

Format for records (please choose only one): Please note if a format is not selected, records will be in paper format.

Paper Fax

PURPOSE Of RELEASE

Continuing of care

Copies for own use

Transfer to another provider

Legal

Other:

AUTHORIZATION FOR GENERAL RELEASE OF INFORMATION

By signing this authorization form, I understand that:

Requests for copies of medical records are subject to reproduction fees in accordance with federal/state regulations.
I have the right to revoke this authorization at any time. Revocation must be made in writing and presented or mailed to the Health Information Management Department at the following address: 516 Pegram Dr Tupelo, MS 38801. Revocation will not apply to information that has already been disclosed in response to this authorization.
Unless otherwise revoked, this authorizaƟon will expire on the following date/event/condition:

If I fail to specify an expiration date/event/condition, this authorization will expire 3 years from the date
signed.

Treatment, payment, enrollment or eligibility for benefits may not be conditioned on whether I sign this authorization.
Any disclosure of information carries with it the potential for unauthorized re-disclosure and the information may not be protected by federal confidentiality rules.

SIGNATURE OF PATIENT/LEGAL REPRESENTATIVE

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 or Legally Responsible Party

Date:

Relationship to patient, if not signed by patient

Your information will be encrypted.