Authorization To Release Healthcare Information

Patient Information

Patient's Name

Date of Birth

Previous Name

Social Security #:

I request and authorize

Provide

Receive

Authorization To Release Information To Family Members

From

Healthcare Provider / Entity Information

Name

Specialty

Street

City

State

Zip Code

Tel

Fax

The Purpose Of Release

This request and authorization applies to:

Continuation of Care

Legal

Transfer of Care

Other:(Please Specify)

Coordination of Care

Other: (Please Specify)

Information To Be Released

This request and authorization applies to:

Entire Record

Visit Notes

Labs / MRI / X-Ray

Dates_____ to_____

Dates

This Consent is subject at any time, except to the extent that action has been taken in reliance on the patient's consent.

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.

Patient Signature

Date Signed

NOTE TO RECEIVER (Notice Prohibiting Redisclosure): This information has been disclosed to you from records protected by federal confidentiality rules(42 CFR Part2). The federal rules prohibit you from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of rht person to whom it pertains or as otherwise permitted by 42 CFR Part 2. A general authorization for the release of medical or other information is not sufficient for this purpose. The federal rules restrict any use of this information to criminality investigate or prosecute any alcohol or drug abuse patient.

Your information will be encrypted.