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Generic Med Recs Auth

This document authorizes the disclosure of a person's health information from their healthcare provider to a specified recipient. It allows for the release of all health records, except any exclusions listed, for a specific purpose. The authorization is valid either for a set time period, until the provider fulfills the request, or until a specified event occurs. The individual or their legal representative must sign the form to authorize the disclosure.

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52 views1 page

Generic Med Recs Auth

This document authorizes the disclosure of a person's health information from their healthcare provider to a specified recipient. It allows for the release of all health records, except any exclusions listed, for a specific purpose. The authorization is valid either for a set time period, until the provider fulfills the request, or until a specified event occurs. The individual or their legal representative must sign the form to authorize the disclosure.

Uploaded by

medonemedical
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
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AUTHORIZATION FOR USE/DISCLOSURE OF HEALTH INFORMATION Name:__________________________________________ Last First Middle S.S.

#:___________________________ Authorization for Use/Disclosure of Information: I voluntarily authorize and direct my health care provider ___________________________________________________ to use or disclose my health information during the term of this Authorization to the recipient that I have identified below. Recipient: Name of person or class of persons to whom my health care provider may disclose my health information ___________________________________________________________________________. Address of the recipient or where my health information should be delivered: _____________________________________________________________________________________ Phone: Fax: . Date of Birth: __________________

Purpose: I understand that the specific purpose of this Authorization is _____________________________________________________________________________________. (Note: at the request of the patient is sufficient if the patient is initiating this Authorization) Information to be disclosed: This authorization permits the above provider to disclose the following medical records: All of my health information that the provider has in his or her possession, including information relating to any medical history, mental or physical condition and any treatment received by me.1 All of my health information described above except for the following: ___________________________________________________________________________________. Only the following records or types of health information: (Insert dates of treatment, types of treatment or other designation.)__________________________________________________________________. Term: This Authorization will remain in effect: From the date of this Authorization until the _____ day of ________, 200_. Until the Provider fulfills this request. Until the following event occurs: __________________________ Signature _________________ Date __________________ Signature of Witness

If Individual is unable to sign this Authorization, please complete the information below: ___ Name of Guardian/Representative
1

______ Legal Relationship

____ Date Witness

NOTE: This Authorization does not extend to HIV test results, outpatient psychotherapy notes, drug or alcohol treatment records that are protected by federal law, or mental health records that are protected by the Lanterman-PetrisShort Act. 04.03

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