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Karilindau Exam 3 Form

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46 views3 pages

Karilindau Exam 3 Form

Uploaded by

api-550527524
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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PATIENT AUTHORIZATION TO RELEASE MEDICAL RECORDS

I, _______________________________________ DOB:___________________
Patient Name
_________________________________________ SS#____________________
Patient Address
authorize ________________________________________________________
Name of Physician, Practice, Facility, etc.
to provide _______________________________________________________
Name of Physician, Practice, Facility, etc.
__________________________________________________________
Name of Physician, Practice, Facility, etc.

The information to be released is (state specific documents, time period, etc.):

_________________________________________________________________
Purpose or need for the information requested:

Continued Care ______ Insurance _____ Legal _____ Transfer _____ Personal _____

I understand this consent is voluntary and that I may revoke this authorization at any time (except to the
extent that action based on this consent has already been taken) by written, dated and signed
communication. This consent will remain in effect no more that (90) days from the date I signed this
consent. I also understand that my medical records may include mental health information,
drug/alcohol information and/or HIV information.

When my information is used or disclosed pursuant to this authorization, it may be subject to re-
disclosure by the recipient and may no longer be protected by the federal HIPPA Privacy Rule.

I understand I may refuse to sign this authorization. If I refuse, the identified records will not be
disclosed. Whether I sign or refuse to sign, my treatment will not be affected.

_________________________________________ ______________ ___________


Patient/Parent/Legal Guardian Signature Relationship Date

_________________________________________ ______________
Witness Signature Date

If not signed by the patient, state relationship and reason for patient’s inability to sign.

A copy of this authorization has been _____ accepted _____ rejected by the patient/representative

A photocopy or facsimile of the authorization will be considered valid unless otherwise specified.

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