Records Release

AUTHORIZATION FOR DISCLOSURE OF
HEALTH INFORMATION
PATIENT:
________________________________________ ________________________________________
Name of Patient/Previous Names Birth Date/Medical Record Number
________________________________________ ________________________________________
Street Address City, State, Zip Code
AUTHORIZES: RELEASE OF PROTECTED HEALTH INFORMATION TO:
________________________________________ ________________________________________
Name of Health Care Provider/Plan/Other Name of Health Care provider/Plan/Other
________________________________________ ________________________________________
Street Address Street Address
________________________________________ ________________________________________
City, State, Zip Code City, State, Zip Code
INFORMATION TO BE RELEASED:
Date of Service Date of Service
Info Necessary for Cont. Care _____________ Discharge Summary _____________
History and Physical _____________ Operative/Procedure Report _____________
Pathology Report _____________ Consultations _____________
Labs _____________ X-rays _____________
EKG/EMG/EEG _____________ PT/SP/OT _____________
ER/UC _____________ Progress Notes _____________
Immunizations _____________ Other __________________________________
(Contact Radiology Department to obtain films)
In compliance with Wisconsin Statutes, which require special permission to release otherwise privileged
information, please release records pertaining to:
Alcohol Abuse or Test Results HIV Test Results, AIDS or AIDS-Related Disease
Drug Abuse or Test Results Sexually Transmitted Disease
Mental Health Other __________________________________
Developmental Disabilities
THIS DISCLOSURE IS BEING MADE FOR THE FOLLOWING PURPOSE(S):
Further Medical Care Workers Compensation
Relocation/Moving Attorney/Court Case
Insurance Change Insurance
At the Request of an Individual Other (comments) ________________________
Changing Physicians (explain) ______________ ___________________________________________
__________________________________________ ___________________________________________
REDISCLOSURE NOTICE: I understand the information used or disclosed based on this authorization may possibly be re-disclosed by the recipient, and/or no longer be
protected by Federal Privacy Standards.
YOUR RIGHTS WITH RESPECT TO THIS AUTHORIZATION:
Right to Inspect or Copy the Health Information to Be Used or Disclosed – I understand that I have the right to inspect or copy the health information I have authorized to
be used or disclosed by this authorization form. I may arrange to inspect my health information or obtain copies of my health information by contacting the Medical Records
Dept. Team Leader. Right to Receive Copy of This Authorization – I understand that if I agree to sign this authorization, I will be provided with a copy of it. Right to
Refuse to Sign This Authorization - I understand I am under no obligation to sign this form and that the person(s) and/or organization(s) listed above who I am authorizing
to use and/or disclose my information may not condition treatment, payment, enrollment in a health plan or eligibility for health care benefits on my decision to sign this
authorization. (Exception: To provide care that is done solely for the purpose of creating information to release to another party, in which case care cannot be provided
without authorizing disclosure. Authorization is needed to release information to payers for certain mental health services and HIV testing. If I refuse to sign the authorization
form for this purpose, I understand I may be responsible for paying the entire bill for these services). Right to Revoke This Authorization – I understand written notification
is necessary to cancel this authorization. To obtain information on how to withdraw my authorization or to receive a copy of my withdrawal, I may contact the Medical Records
Dept. I am aware that my withdrawal will not be effective as to uses and/or disclosures of my health information that the person(s) and/or organization(s) listed above have
already made in reference to this authorization.
Expiration Date: This authorization is good until the following date(s) ____________________________________________________ or for one year from the date signed.
I have had an opportunity to review and understand the content of this authorization form. By signing this authorization, I am confirming that it accurately reflects my wishes.
SIGNATURE PATIENT/LEGAL REP: ____________________________________ DATE: __________________

(If signed by other than patient, state relationship and authority to do so.)
Parent Guardian POA for Healthcare Spouse/Adult Family Member of Deceased Patient
Rev. 04/2003
PC36770

Records Release

Uploaded by

Document Information

Original Description:

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Records Release

Uploaded by

Copyright:

Available Formats

AUTHORIZATION FOR DISCLOSURE OF

AUTHORIZES: RELEASE OF PROTECTED HEALTH INFORMATION TO:

SIGNATURE PATIENT/LEGAL REP: __________________ DATE:

You might also like