HIPAA Authorization for Disclosure of Personal Health Information

This Authorization is provided in accordance with the Health Insurance Portability and Accountability Act (HIPAA). The HIPAA Privacy Rule protects the confidentiality of your medical information, referred to as “protected health information” (PHI). Spectrum Clinical Research is required to obtain this Authorization in order to use and disclose your PHI for purposes including, but not limited to, medical care, treatment, payment, coordination of health services, administrative operations, and participation in clinical research activities when applicable.

This Authorization is voluntary, and you have the right to refuse to sign it. However, without your Authorization, Spectrum Clinical Research may be unable to access or share your medical records as needed for these purposes. You may revoke this Authorization at any time by submitting a written request. Such revocation will not affect any uses or disclosures made in reliance on this Authorization prior to the date of revocation.

Patient Information:

Last Name (Per Social Security card)

First Name

Middle Initial

Date of Birth

Social Security Number

Telephone #

Street Address

City

State

Zip Code

I agree to release the following institutions or health care networks to disclose my medical records:

Healthcare Provider

Clinic/Institution Name

Address:

City, State

Zip Code

Tel:

Fax:

Select One (required):

All Medical Records:

I request the release of my complete health record, which may or may not include protected health information (PHI) and electronic protected health information (ePHI) protected under HIPAA.

Medical Records ONLY related to: Medical Records Other:

Add new row

Purpose:

The purpose of this authorization is to permit the use and disclosure of my protected health information as required or permitted by law, and for purposes related to general medical care, treatment, payment, healthcare operations, coordination of care and participation in clinical research activities, when applicable.

Recipient:

Spectrum Clinical Research
Address: 2700 Clay Edwards Dr. Suite 260
Kansas City, MO 64116
Email: medicalrecords@spectrumclinicalresearch.com
Fax: 816.466.5286
Phone: 816.865.6466

Expiration:

This Authorization will not expire unless a specific expiration date or event is stated, or unless it is revoked in writing by the individual signing this form.

Expiration event or date:

Authorization:

By signing below, I acknowledge that I have read and understand this Authorization form and have been given the opportunity to ask questions. I understand that signing this Authorization is required for Spectrum Clinical Research to access, use, or disclose my health information for purposes including, but not limited to, clinical research, medical care coordination, and related administrative functions.

I further authorize Spectrum Clinical Research and its technology partners—including, but not limited to, DrChrono and Third Opinion—to access, transmit, and receive my health information through national Health Information Exchange (HIE) networks, including but not limited to Surescripts Record Locator & Exchange (RLE) and Carequality. This may include retrieval of my past and current medical records, diagnoses, medications, laboratory results, and visit summaries from other healthcare providers or organizations that participate in these networks. This information will be used solely for research eligibility screening, care coordination, and continuity of services, in accordance with HIPAA and applicable federal regulations.

I understand that I may revoke this Authorization at any time by submitting a written request. Such revocation will not affect any use or disclosure made in reliance on this Authorization prior to receipt of the revocation.

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.

Patient or Personal Representative Signature

Date

Printed Name

If this form was signed by a personal representative on behalf of the patient, please check the appropriate box to indicate your relationship to the patient.

Parent

Legal Guardian

Other:

If other, Specify:

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.

Witness Signature

Date

Printed Name

Your information will be encrypted.