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Member
Name:
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Member
Address:
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Member
Telephone:
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This authorization allows
the recipient to use or disclose my protected health information (PHI) for
the following
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 purpose:
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 I request and
authorize
to release personal information to:
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Name:
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Address:
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City,
State:
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Zip
Code:
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Telephone:
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This request and
authorization applies to the type and amount of information to be used or
disclosed as follows: (include dates where appropriate)
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    Problem List Medication List List of Allergies Immunization Record
Most recent history and
physical Most recent discharge summary
Laboratory results from (date) to (date)
X-ray and Imaging reports from (date) to (date)
Consultation Reports Entire Record
Other
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I understand that:
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Ø
I understand that the information in my health record may include
information relating to sexually transmitted disease, AIDS or HIV. It may also include information about
behavioral or mental health services, and treatment for alcohol and drug
abuse.
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I may withdraw my authorization at any time by submitting a written
request to the Health Information Management
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Department.
If I do, I understand that my personal information my have already been
released after I gave permission. I understand
the revocation will not apply to my insurance company when the law provides
my insurer with the right to contest a claim
under my policy.
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Information used or disclosed pursuant to this authorization may be
subject to redisclosure by the recipient and no longer protected by federal or state privacy
laws.
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I understand that this authorization will automatically expire on the
following date, event or condition:
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 If I
fail to specify an expiration date, event or condition, this authorization
will expire in six months.
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I understand that I have the right to refuse to sign this
authorization and that my refusal will not result in the condition of
treatment, payment, and enrollment in my employers group health plan or
eligibility for benefits. I understand that I may inspect or copy the
information to be used or disclosed.
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I
have carefully read and understand the above and have had any questions
explained to my satisfaction. I do herein expressly and voluntarily authorize
disclosure of the above information about, or medical records of my condition
to those persons or agencies listed above.
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 Member (or personal representative) signature:
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 Print name:
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 Date:
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If signed by member’s
personal representative, please attach documentation of authority (e.g.,
power of attorney, signed authorization).
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Mail Completed Form to: __________________________
__________________________
__________________________
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