Authorization for Release of Information

 

I hereby authorize ____________________________________ to disclose my individually identifiable health information as described below, which may include information concerning communicable diseases such as Human Immunodeficiency Virus (“HIV”) and Acquired Immune Deficiency Syndrome (“AIDS”), mental illness (except for psychotherapy notes), chemical or alcohol dependency, laboratory test results, medical history, treatment, or any other such related information. I understand that this authorization is voluntary and I may refuse to sign this authorization. I further understand that my health care and the payment of my health care will not be affected if I do not sign this form.

 

I understand that if the recipient authorized to receive the information is not a covered entity, e.g. insurance company for health care provider, the released information may no longer be protected by federal and state privacy regulations.

 

________________________________________________________________________________________________

Print Patient Name                                                                            Date of Birth                         Social Security Number

________________________________________________________________________________________________

Dates(s) of Service (if known)                                                                                                        Medical Record Number

 

Description of information to be released: (check all that apply)

q    Face Sheet	q    Radiology Reports	q    Radiology Films  (Imaging Department)
q    Discharge Summary	q    Laboratory Reports	q    Billing Records  (Patient Financial Services)
q    History & Physical	q    Pathology Reports	q    Other: ______________________________
q    Consultation Reports	q    Diagnostic Reports
q    Operative Reports	q    Emergency Room

The purpose of the disclosure is for the following: (check the appropriate category)

q   Patient Request: (circle type of disclosure)

Hospital                 Physician               Insurance              Attorney

Other Please explain: __________________________________________________________________________                

q    Hospital Request: Explain purpose of authorization ________________________________________________

(If a hospital request, the patient must receive a copy of the authorization)

 

The information described herein will be sent to the following address: (if applicable)

 Capitol City Records Service, Inc.  · 4000 Medical Parkway · Suite 201 · Austin, TX 78756

 

I understand that this authorization will expire 180 days from the date of this authorization unless I otherwise specify.
I desire this authorization to be in effect until____________________________________.

                                                                                                            (Expiration event/date)

I further understand that I may revoke this authorization at any time by notifying said hospital in writing. I also understand that the written revocation must be signed and dated with a date that is later than the date on this authorization. The revocation will not affect any actions taken before the receipt of the written revocation.

 

___________________________________________________________________

Signature of Patient or Patient’s Representative                            Date

 

___________________________________________________________

Printed name of Patient’s Representative

 

___________________________________________________________

Relationship to Patient 

                      

___________________________________________________________

Legal Authority (attach supporting documentation)