Enter content here Name of Practice:
__________________________________________________________________________________________

Telephone #: ____________________________________   Fax #: _____________________________________

Authorization to Use or Disclose My Health Information

Patient name: _______________________________________________   Date of birth: ____________________

YOU MAY USE OR DISCLOSE THE FOLLOWING HEALTH CARE INFORMATION:

Please check all that apply:

All my health information maintained by the above named practice(Circle to Include/Exclude the following Health Information:)

Include/Exclude – Drug Abuse

Include/Exclude – Alcohol Abuse

Include/Exclude – Psychological or Psychiatric

Include/Exclude – HIV/AIDS

My health information relating to the following treatment or condition: ___________________________________

My health information for the date(s):  ___________________________________________________________

Other: ___________________________________________________________________________________

YOU MAY DISCLOSE THIS HEALTH INFORMATION TO:

Name (or title) and organization: _________________________________________________________________

Address: ___________________________    City: ____________________   State: _________   Zip: ___________

Telephone #: ____________________________________   Fax #: _____________________________________

REASON (S) FOR THIS AUTHORIZATION (check all that apply):

Transferring care/Leaving practice

At my request/Personal use

Other (Specify):  ___________________________________________________________________________

This authorization ends: On (date) _______________________________________________________________

MY RIGHTS

I understand I do not have to sign this authorization in order to get health care benefits (treatment, payment, or enrollment). However, I do have to sign an authorization form to take part in a research study or to receive health care when the purpose is to create health information for a third party. I may revoke this authorization in writing. If I do, it will not affect any actions already taken by the above named practice based upon this authorization. I may not be able to revoke this authorization if its purpose was to obtain insurance. Once the office discloses health information, the person or organization that receives it may re-disclose it. Privacy laws may no longer protect it.

________________________________________________________________________________________________________

Patient or legal authorized individual signature
________________________________________________________________________________________________________

Date _________________   Time _________________________

Printed Name if signed on behalf of the patient
Relationship (parent, legal guardian, personal representative, etc)
*Effective 11/08 – Medical Records fees are as Follows: $14.00 for the first 10 or fewer pages, $.50/pg for pages 11-40, and $.33/ page there after.