PROVIDENCE PARK DRIVE, MOBILE AL 36695
AUTHORIZATION FOR RELEASE OF IDENTIFYING HEALTH INFORMATION
Patient Name: _______________________________________________________Date of Birth: ___________________ Acct#______________
Patient Phone #___________________________________________________________ SS #: _____________________________________
Patient Mailing Address: ________________________________________________________________________________________________
City ____________________________________________________ State: ______________________ Zip: ____________________________
REQUEST RECORDS: TO BE OBTAINED FROM:
_________________________________________________ PHONE#_________________ FAX#: _________________
(Practice OR Doctor First and Last Name)
I authorize___________________________________________________________________ (Dr’s first and last name and/or practice) to release health information identifying me (including if applicable, information about HIV infection or AIDS, information about substance abuse treatment, and information about mental health services) under the following conditions:
THE FOLLOWING QUESTIONS MUST BE ANSWERED TO COMPLETE REQUEST-
1. Detailed description of the information to be released: Complete medical record including any and all medical history, exams, diagnostic and lab test, op reports, prescriptions, optical orders and demographics/billing information______ Specific records listed only ________________________________
2. The purpose(s) for the release (if the authorization is initiated by the individual).
It is permissible to state “At the request of the individual” as the purpose, if desired by the individual.
Please state purpose: At the request of the individual _______________ Other: _______________________________________________________
3. Expiration date or event relating to the individual or purpose for the release:
One Year _______ Six Months _______ Three Months_______ After this occurrence _______ Other ___________
RECORDS TO BE SENT TO:
_______________________________________________________________________ PHONE#_________________ FAX#: _________________
(Practice OR Doctor First and Last Name)
It is completely your decision whether or not to sign this authorization form. We cannot refuse to treat you if you choose not to sign this authorization. If you sign this authorization you can revoke it later. The only exception to your right to revoke is if we have already acted in reliance upon the authorization. If you want to revoke your authorization, send us a written notice or electronic note telling us that your authorization is revoked. Send this note to the office listed at the top of this form. When your health information is disclosed as provided in this authorization, the recipient often has no legal duty to protect its confidentiality. In many cases, the recipient may re-disclose the information as he/she wishes. Sometimes state or federal law changes this possibility.
I HAVE READ AND UNDERSTAND THIS FORM. I AM SIGNING IT VOLUNTARILY. I AUTHORIZE THE DISCLOSURE OF MY HEALTH INFORMATION AS DESCRIBED IN THIS FORM.
Name: _________________________________________________________________________________________ Date: ___________________
If you are signing as a personal representative of the patient, describe your relationship to the patient and the source of your authority to sign this form:
RELATIONSHIP TO PATIENT: _____________________________________________________________
Source of Authority: _______________________________________________________________________
(Court appointment, legal guardian, Power of Attorney, Parent)
Confidentiality Note: The information contained in this facsimile message is legally privileged and confidential information, which is intended only for the use of the party named above. If the reader of this message is not the intended recipient, you are hereby notified that any use, dissemination, distribution, or reproduction of this message is strictly prohibited. If you have received this facsimile in error, please immediately notify us by telephone and return the original message to use at the address above. Thank you.