THIS FORM MUST BE COMPLETED IN THE ENTIRETY

BY THE PATIENT OR THE PATIENT’S AUTHORIZED REPRESENTATIVE

AUTHORIZATION FOR DISCLOSURE OF PROTECTED HEALTH INFORMATION (PHI)

Patient Name Hariharan Alavandan Maiden or Other Name(s)

Date of Birth 04-13-1989 Phone Number 513-226-2705 Email Address

[email protected]
Address 1100 A Mont Michel Apartments, 688 Riddle Road,

1. Provider Making the Use or Disclosure: I authorize the below Provider(s) (referred to as “Health Care
Provider”) to release my/the patient’s individually identifiable health information as described below in
Section 3. Please add Provider and Location below when known.

❑ Bethesda Arrow Springs ❑ Good Samaritan Hospital ❑ TriHealth Physician Practices

❑ Bethesda Butler ❑ Good Samaritan Glenway (including Group Health and
❑ Bethesda Family Practice ❑ Good Samaritan Western Ridge Queen City Physicians) You
❑ Bethesda Hand Rehabilitation ❑ McCullough-Hyde Memorial MUST fill out Provider and
❑ Bethesda North Hospital Hospital Location below.
❑ Bethesda Healthcare (aka ❑ TriHealth Walgreens
TriHealth Corporate Health) ❑ TriHealth Priority Care
Good Samaritan Emergency Deparment
Provider: ________________________________________________________________________________
Cincinnati
Location: ________________________________________________________________________________

2. Recipient of the Information: I authorize the Health Care Provider to release the information described
in this release to: ❑ SELF
Hariharan Alavandan
Name: ___________________________ 513-226-2705
Phone: __________________ Fax: ________________________
688 Riddle Road, 1100 A Mont Michel Apartments
Street Address: ___________________________________________________________________________
Cincinnati
City/State/Zip: __________________________ Secure Email Address:_______________________________
[email protected]

Preferred Method of Delivery: ❑ MyChart ❑ Print ❑ Fax ❑ Secure Email ❑ Electronic Media (CD or flash drive)

3. Type of Information to be Released: Describe the type of information that you want to be disclosed pursuant
to this Authorization.
❑ Billing Records ❑ Hospital Medical Records ❑ Images (CD) ❑ Physician Office Notes
Date(s) of Treatment (Please DO NOT leave blank):
05-29-2025
___________________________________________________________________________
___________________________________________________________________________
PHI to be Released:
❑ Test Results (Lab and Imaging) ❑ Abstract of Health ❑ Entire Encounter CD
❑ Other: ____________________

Further, I authorize the release of any information contained in the above records concerning treatment of drug or
alcohol abuse, drug-related conditions, alcoholism and/or Acquired Immune Deficiency Syndrome (AIDS) and/or
 testing for antibodies to the AIDS virus (HIV) an/or psychiatric/psychological conditions and/or psychiatric/mental
health treatment.

4. Your Refusal to Sign this Authorization: The Health Care Provider may not condition treatment on whether or
not you sign this Authorization. If you refuse to sign this Authorization the Health Care Provider will not withhold
treatment from you and will not release the information to the person or organization specified above.

5. Purpose for the Use or Disclosure: The purpose for the disclosure is at the patient’s request (if the request Is
initiated by the patient) or one or more of the following reasons: CHECK ALL THAT APPLY
❑ Lawsuit/Legal Preparation ❑ Applying for disability ❑ Applying for insurance

❑ Other:__________________________________________________________________________________

6. Oral Communications: I understand that this Authorization allows the Health Care Provider (and its team members)
to discuss my individually identifiable health information described herein with the recipient of the information.
7. Re-disclosure: I understand that the information used and/or disclosed pursuant to this Authorization may be re-
disclosed by the recipient of the information and may no longer be protected by Federal Law. However, if the
information disclosed pursuant to this Authorization includes alcohol or drug treatment records, the person(s)
receiving such disclosure is hereby notified that this information has been disclosed from records protected by
Federal confidentiality rules (42 CFR part 2). The Federal rules prohibit such person(s) from making any further
disclosure of this information unless further disclosure is expressly permitted by the written consent of the patient
to whom it pertains or as otherwise permitted by 42 CFR part 2. A general authorization for the release of medial or
other information is NOT enough for this purpose. The Federal rules restrict any use of the information to criminally
investigate or prosecute any alcohol or drug abuse patient. If the information disclosed pursuant to this
Authorization includes the identity of an individual on whom an HIV test is performed, HIV test results or AIDS-
related treatment information, the person(s) receiving such disclosure is hereby notified that this information has
been disclosed from confidential records protected from disclosure by Ohio law. Ohio law prohibits such person(s)
from making any further disclosure of this information without the specific, written, and informed release of the
patient to whom it pertains, or as otherwise permitted by Ohio Law. A General authorization for the release of
medical or other information is not sufficient for the purpose of the release of HIV test results or diagnoses.
8. Revocation: I understand that I may revoke this Authorization at any time by notifying the Health Care Provider in
writing by sending a letter to the attention of the Manager of Medical Records Department at the Health Care
Providers mailing address. I understand that if I revoke this Authorization, it will not affect any actions that the
Health Care Provider took before it received by revocation letter.
9. Expiration: This Authorization will expire one year after the date below, or sooner by choice, in which case this
Authorization will expire on: _____________________ (If applicable, insert date of the foregoing line. Note: You
may not indicate that there is no expiration; for example, the words “does not expire” or “no expiration” or “none”
are not acceptable). However, if the records to be used or disclosed pursuant to this Authorization concern
psychiatric, psychological and/or mental health treatment, this Authorization will expire 90 days after the date
below, or sooner by choice in which case this Authorization will expire on _____________ (If applicable, insert date
on the foregoing line. Note: You may not indicate that there are no expirations; for example, the words, “does not
expire: or “no expiration: or “none” are not acceptable.

______________________________________________________________ 05-29-2025
__________________________________
SIGNATURE OF PATIENT OR PATIENT’S REPRESENTATIVE DATE

Printed Name of Patient’s Representative, if Applicable: ___________________________________________________

Relationship to Patient: ❑ Parent ❑ *Legal Guardian ❑ Other _______________________

*Legal documentation of Representative’s authority must accompany this Authorization.

Please note that there may be a charge to copy records.

The Health Care Provider may use a copy service and it may bill you directly.

Rev 3/19/2025