Authorization for Release of Protected Health Information / Access Request Form

I authorize

Facility Name & Address

to release:

For the record(s) of:

Patient Name

Date of Birth

Address

City

State

Zip

Telephone

Specify date(s) of care of diagnostics to be released

For the purpose of: Information will be used/disclosed for the following purpose(s):

Drug and/or Alcohol Abuse and/or Psychiatric and/or HIV/AIDS Records Release

If my medical or billing record contains information about drug and/or alcohol abuse, mental health, sexually transmitted diseases and/or other sensitive information I agree to release.

Drugs

Yes No

HIV/AIDS

Yes No

Sexually Transmitted Disease

Yes No

Alcohol

Yes No

Mental Health

Yes No

Genetic/Metabolic Testing

Yes No

Time Limit / Right to Revoke

This authorization will expire 90 days from the day of my signature on the following date or event (please specify):

If you want to cancel this authorization before it expires, I may submit a written notice to the Health Information Services Team Leader at Pediatric Care North. It is understood that information released prior to my written cancellation was made at my request and with my consent.

Re-Disclosure

I understand that the information disclosed by this authorization could be re-disclosed by the person receiving it and is no longer protected by federal or state legal privacy requirements. Pediatric Care North, its affiliates, its employees and officers are not legally responsible or liable for the re-disclosure of the information indicated on this authorization.

Signature or Patient or Personal Representative Who May Request Disclosure

I understand that I do not have to sign this authorization, that my treatment or payment for services will not be denied if I do not sign this Authorization and I can inspect or copy the protected health information to be used or disclosed.

Signature of Patient of Patient's Representative

Date

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

Relationship of Patient Representative (if applicable)

The information disclosed to you may be from records protected by Federal confidentiality rules (42 CFR Part 2). The Federal rules and state law prohibit you from making any further disclosure of this information unless further disclosed expressly permitted by the written consent of the 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 the information to criminally investigate or prosecute any alcohol or drug abuse present.

For Office Use Only

Identity of Requestor Verified via:

Photo ID Matching Signature Other (please specify)

Other Specify

Verified by:

Send to:

Name:

Date

Address:

Phone #:

Your information will be encrypted.