AUTHORIZATION FOR USE OR DISCLOSURE OF PROTECTED HEALTH INFORMATION / ACCESS TO PROTECTED HEALTH INFORMATION FORM
Instructions for Completing Authorization for Release of Information Form
- Complete All Questions
- Section l: enter your name and date of birth or the name and date of birth of the patient whose health information is to be released and select the facility releasing medical records and print
- Section Il: enter the name and full address of the facility/individual to receive the health information being released.
- Section Ill: check the appropriate box as applicable to select the type of medical records you want released.
- Other (specify) e.g., Purchased Referred Care (PRC), Billing, Employee Health.
- All Records -- complete record including, if authorized, the sensitive information such as alcohol and drug abuse treatment/referral, sexually transmitted diseases, HIV/AIDS-related treatment and mental health other than psychotherapy notes.
- Consent to Discuss Participation in Services if checked, gives your authorization for our caseworkers to discuss your progress and/or details about your participation in services or programs at our facility.
- Section IV: enter the date range of medical records to be released. Specify date range, e.g., Jan. 1 , 2002, to Feb. 1, 2002.
- Section V: state the reason why the information is needed, e.g., court, continued medical care, etc.
- Section VI: check the appropriate box to indicate the format in which to release the health records.
IN ORDER TO RELEASE SENSITIVE INFORMATION REGARDING ALCOHOL/DRUG ABUSE
TREATMENT, HIV/AIDS-RELATED TREATMENT, SEXUALLY TRANSMITTED DISEASES AND/OR MENTAL HEALTH RECORDS (OTHER THAN PSYCHOTHERAPY NOTES), THE APPROPRIATE BOX OR BOXES MUST BE CHECKED BY THE PATIENT.
8. A copy of the completed Authorization for Release of Information Form (UL840020) will be given to you with your medical record when released.