Patient Name

Birth Date

Address ________________________________________ Telephone _______________________

City _______________________________ State ________________  Zip Code _______________

For disclosure only

I hereby authorize _____________________________________________________________________

                                  Practice or Provider Name

to disclose medical information and/or protected health information of the patient listed above to:

___________________________________________________________________________________

Practice or Provider Name

_________________________________________   ___________________________   ___________   _______________

Address                                                                          City                                                   State                 Zip Code

Purpose: ___________________________________________________________________________________________

For treatments date(s) (if applicable): ____________________________________________________________________

1 Entire clinical record

1 Billing record

1Emergency Room

1History and Physical

1 Consult Report

1 Operative Report

1 Lab

1 Imaging/Radiology

1 Demographics

1Nursing notes

1Medication record

1 Rehabilitation services

1 Progress notes

1 Physician orders

1 Other _______________

______________________

Expiration: This authorization shall expire upon (check one):

1 Fulfillment of this request

1 Date: ________________

I acknowledge, and hereby consent to such, that the released information may contain alcohol, drug abuse, psychiatric, HIV testing, HIV results or AIDS information.

I understand that this authorization may be revoked by me at any time except to the extent that action has been taken in reliance upon it.  The information used or disclosed pursuant to the authorization may be subject to re-disclosure by the recipient and no longer protected. 

Fees/charges will comply with all laws and regulations applicable to release of information.

I have read the above and authorize the disclosure of the protected health information as stated. 

________________________    ___________________________________________________________   _____________________

Date                                                Signature of patient/Parent/Patient Representative                                       Relationship to patient

___________________________________________________________________________________________________________

Address and telephone number of requestor (if different from patient information)