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Authorization

This document is an authorization form for the use or disclosure of a patient's protected health information (PHI). It outlines the patient's rights regarding the release of their medical records, including options for the type of records requested and the method of delivery. The authorization is voluntary and includes a revocation clause, with an expiration date for the authorization specified by the patient.

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William Oliver
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4 views

Authorization

This document is an authorization form for the use or disclosure of a patient's protected health information (PHI). It outlines the patient's rights regarding the release of their medical records, including options for the type of records requested and the method of delivery. The authorization is voluntary and includes a revocation clause, with an expiration date for the authorization specified by the patient.

Uploaded by

William Oliver
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Authorization for Use or Disclosure of Patient Information

I hereby authorize the use or disclosure of my protected health information (“PHI”) as described below.
This request includes any information relating to drug, alcohol use/treatment, communications with
psychiatrists or psychologists, and records pertaining to sexually transmitted diseases, if they are a part of my
medical record. I understand that this Authorization is voluntary. Once this information has be disclosed, it
may be subject to re-disclosure and no longer be protected by federal regulations.

Patient Information (please print)

Patient Name: _________________________________________ Patient Birthdate: ______ /______ /______

Patient Street/Mailing Address: ________________________________________________________________

City, State, and Zip: _______________________________________ Patient Phone: ______________________

UAB Medicine should provide records to ____me for my personal use or to ____the party indicated below:

Name of person/organization receiving my information: ____________________________________________

Street address: __________________________________ City: ____________________ State: ____ Zip: _____

Are you requesting psychiatric or substance use records to be included in the release? ____Yes____ No

Date range for records: From _______________ to _______________ OR specific date: __________________
(If no date is listed, records for the past 12 months will be provided.)

____ If your records are going to another provider, please check here and they will be provided with the
continuity of care/treatment package.

Select the record package that best meets your need for this Authorization:

____ Package 1 - Key Clinical Notes: Current history and physical, discharge summary, operative reports,
outpatient clinic notes, Emergency Department provider documentation

____ Package 2 - Clinical Notes: Package 1 plus medication list and orders

____ Package 3 – Clinical Notes II: Packages 1 and 2 plus diagnostic reports and laboratory test results

____ Package 4 – Laboratory test results, Radiology reports, and other diagnostic reports

____ Package 5 - Entire Medical Record: Package 3 plus nursing documentation. Excludes Fetal Monitoring
strips- if needed, please select below.

If you selected Package 1, 2, 3, 4, or 5 above, the following documentation, except billing records, Fetal
Monitoring, and Radiology images, will be included in your selected package. However, if your request is
specifically for any of the following only, please check the appropriate box(es):

____ Operative/Procedure Report(s) ____ Emergency Department Documentation

____ Discharge Summary ____ Outpatient Clinic Notes ____ Billing Records ____ Medication List

____ Fetal Monitoring Strips

____ Radiology Images: Please specify images needed: ____________________________________________

____ Other specific record needed: ____________________________________________________________


Authorization for Use or Disclosure of Patient Information
Records Delivery (select one)

____Paper:
NOTICE: If I request records in electronic form, I
____Mailed to address on this Authorization. understand that the records will be encrypted to
help protect my privacy and the security of my
health records and that I will be furnished with the
____ Pick up by _______________________________ information on how to access those encrypted
records. UAB Medicine is not responsible for the
____Electronic: privacy and security of the electronic records on the
CD or in an email once they are received by the
intended recipient.
____Faxed to number: _________________________

____CD (mailed only to address on this Authorization)

____Email to address: __________________________

The patient or the patient’s representative must read and acknowledge the following statements by initialing
each blank:

_____ I understand that I may revoke this Authorization at any time by notifying the entity privacy
coordinator in writing, but if I do, it will not be effective for disclosures made prior to my revocation in
reliance on the Authorization.
_____ I understand that UAB Medicine may not condition the provision of treatment, payment, and
enrollment in a health plan, or eligibility for benefits on signing this Authorization, except under the
following circumstances:
 Participation in research projects can be conditioned on my signing an Authorization to use and
disclose PHI in the research.
 Initial enrollment in health plans can be conditioned on signing an Authorization for the health
plan to review PHI to make eligibility determinations.
 Furnishing healthcare services to me at the request of a third party can be conditioned on me
signing an Authorization for disclosure of the PHI to the third party requesting the treatment.

This Authorization will expire on: _____________________________________.


If I fail to specify an expiration date or event, this Authorization will expire six months from the date on which
it was signed.

Signature of patient or personal representative: ___________________________________________________

Printed name of patient: ______________________________________________________________________

Printed name of personal representative: ________________________________________________________

Relationship to the patient: ________________________________________ Date: ______________________

Return Completed Form:


UAB Health Information Management
Release of Information Office
1201 11th Ave. South
Birmingham, AL 35205
Fax: 205-930-6721

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