AUTHORIZATION FOR THE RELEASE/DISCLOSURE OF PROTECTED HEALTH INFORMATION

Patient Name:

Date of Birth:

Address:

Telephone:

The above patient listed hereby gives permission to Colorectal Health Northwest to (check one):

Release Protected Health Information to: Obtain Protected Health Information from:

Name:

Address:

Phone:

Fax:

I expressly request that the designated record custodian disclose full and complete protected health information including the following (initial each item to be included):

NOTE: INITIAL IN THE BOX NEXT TO THE RECORDS YOU WOULD LIKE RELEASED. ONLY THOSE ITEMS INITIALED WILL BE INCLUDED IN THE RELEASED INFORMATION

All hospital records

Date Range

Clinician office chart notes

Medical records needed for continuity of care

Lab reports

Operative reports

Pathology reports

Diagnostic imaging reports

*Federal Regulation 42CFR Part 2, requires a description of how much and what kind of information is to be disclosed. Provide a specific description of information on reverse of this form*

NOTE: INITIAL IN THE BOX NEXT TO THE RECORDS YOU WOULD LIKE RELEASED. ONLY THOSE ITEMS INITIALED WILL BE INCLUDED IN THE RELEASED INFORMATION

HIV/AIDS related records

Genetic testing information

Drug/alcohol diagnosis, treatment or referral information as listed on back

This release will expire in 180 days. I understand that I sign this form voluntarily and that I may change my decision at any time. Although I understand that I cannot do anything about information previously authorized in release, I am aware that I must notify Colorectal Health Northwest in writing if I would like to revoke this release. A copy of this form is as valid as the original.

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

Authorizing Signature

Date:

Your information will be encrypted.