HTML Preview Patient Medical Records Release Form page number 1.
Patient Authorization to Disclose Protected Health Information
#CHCR-004 rev. 12/12
Patient Label
Page 1 of 1
Patient Authorization to Disclose Protected Health Information
Authorization: I certify that this request is made voluntarily and that the information given above is accurate to the best of my knowledge.
I understand that I may revoke this authorization at any time in writing by submitting my request in writing to the designated Health
Information Management / Medical Records department. If I have authorized the disclosure of my health information to someone who
is not legally required to keep it private, it may be re-disclosed and may no longer be protected. A copy or fax of this authorization will
be as valid as the original.
I understand that authorizing disclosure of health information is voluntary. I understand that I may refuse to sign this authorization and
that my refusal to sign will not affect my ability to obtain treatment, payment, or my eligibility to obtain benefits. I understand that I
may inspect or obtain a copy of the information to be disclosed. I understand a fee may be charged for copies of my medical record.
I understand the facility will provide me a copy of the signed authorization form. If I have questions about disclosure of my health
information, I can contact the designated Corporate Responsibility and Privacy Officer.
Expiration:
Without my express revocation, this authorization will automatically expire upon satisfaction of the need for disclosure, but
in any event will expire 90 days from the date hereof, unless a different date is specified here:
_____________________________________
Acknowledgement: I understand that the information to be disclosed may include any or all information involving communicable or
venereal disease, psychological or psychiatric conditions, drug or alcohol abuse and/or alcoholism. It may also include, but is not
limited to, diseases such as hepatitis, syphilis, gonorrhea and human immunodeficiency viruses (HIV), also known as acquired immune
deficiency syndrome (AIDS).
For Marketing/Fundraising Purposes Only, if applicable: I understand that Centura Health
will will not receive remuneration,
either direct or indirect, as a result of the marketing that I hereby authorize.
SIGNATURE:
___________________________________________________________________________________
DATE:
__________________________________________
Patient (Parent or Legal Guardian)
Minor’s signature is required for release of any records for treatment which the minor may authorize under Colorado Law.
Relationship (if other than patient):
________________________________________________
Power of Attorney Death Certificate
Name of individual signing on behalf of patient:
_______________________________________________________________________________________
Verification: Drivers License #
________________________________________________
Other Appropriate ID:
__________________________________
OFFICE USE ONLY: Attach copies of required identification.
Number of pages released:
_________________
Completion date:
Delivery method:
_________________________
Name of individual who received request:
_______________________________________________
Date received:
____________________________
Patient Medical Record Number / Account Number:
_______________________________________
/
_________________________________________
I hereby authorize the facility listed below to disclose/release the Protected Health Information specified in this request to the
organization, agency or patient named.
AUTHPHI
Patient Name Date of Birth Last 4 of Social Security Number
Address City, State, Zip Code Telephone Number
Release by:
____________________________________________________________
Facility
____________________________________________________________
Address
____________________________________________________________
City, State, Zip Code
____________________________________________________________
HIM Phone/Fax Numbers
Treatment Date(s):
____________________________________________________
Purpose: Further Medical Care Workers’ Comp
Personal Use Insurance Legal
Marketing/Fundraising
Other:
_______________________________________________________________
Pertinent Protected Health Information Allowed to be Included:
Discharge Summary Radiology Special Studies Entire Medical Record
History & Physical/Consult Outpt Record Medication Records
Operative Report Progress Notes Psych Health Records
Labs Physician Orders Other (specify):
_______________________________________________________
*Psychotherapy Notes are distinct and may not be included with the disclosure of any other protected health information.
A Patient Authorization to Disclose Psychotherapy Notes must be completed.
Type of Disclosure Authorized & Delivery Instructions:
Provide copies of records to organization/agency/individual
Mail records directly to address above
Call to pick-up records:
____________________________________
Fax records to:
____________________________________________
Release to:
____________________________________________________________
Organization, Agency, Individual
____________________________________________________________
Attn:
____________________________________________________________
Address
____________________________________________________________
City, State, Zip Code