Authorization for Release of Information

423 N 3rd Avenue, Suite 210, Sandpoint, Idaho 83864

Phone (208) 263-2173 • Fax (208) 263-7441

The HIPPA Privacy Law allows Sandpoint Women’s Health to charge for copies of records. See reverse for details.

Specific description of information (including dates):

By initialing below, I specifically authorize the release of information relating to the diagnosis/treatment of:

I hereby release the providing person(s)/organization(s) from all legal liability that might arise from the release of this sensitive information protected by Title 42 of the Code of Federal Regulations. 

I hereby authorize the use or disclosure of my individually identifiable health information as described above. I understand that this authorization is voluntary. I consider a copy of this authorization be as valid as the original. I understand that if the organization authorized to receive the information is not a health plan or health care provider, the released information may no longer be protected by federal privacy regulations. I understand that I may see and obtain a copy of the information described on this form if I ask for it and that I may get a copy of this form after I sign it. I understand that a fee for copies may be imposed by the person(s)/organization(s) listed above or by its designated business associate.

I understand that this authorization will expire one year from the date of my signature. I understand that I may revoke this authorization at any time, except to the extent that action has already been taken to comply with it, by notifying the person(s)/organization(s) listed above.

Prohibition of Redisclosure: This information has been disclosed to you from records whose confidentiality is protected by federal law. Federal regulations (42 CFR 164.508) prohibit you from making further disclosure of this information except with the specific written consent of the person to whom it pertains. A general authorization for release of medical or other information if held by another party is NOT sufficient for this purpose.

CORE CHART (up to 10 pages) for personal use:

• Three most recent dates of service.
• Last prenatal record (if applicable)
• Most recent blood work, pap smear, biopsy, etc.
• Provided at no charge

The above documents are typically considered sufficient for continuity of care. If you would like your entire record release, you will be charged for these services (see below Pre-payment may be required prior to fulfilling your request.

Request of more than 10 pages for personal use:

• 30 pages or less = $0.10 per page
• 31+ pages = $0.05 per page
• Additional cost for postage applies

Request for records going to a 3rd party, attorney, or insurance company:

• $25.00 clerical fee
• 30 pages or less =  $0.50 per page
• 31 + pages =  $0.25 per page
• Additional cost for postage applies 

Requests are generally filled within two (2) weeks. If your need is more urgent that our customary timeline, an additional $10.00 processing fee will be incurred.

Please Note: This notice applies to request for medical records for the clinic only. If you require medical records from the hospital medical records department directly.

2. More than 10 pages for personal use # of pages over 10:

rd 3. Records for a 3 party (Addl $25.00 fee) # of pages:

4. Urgent request (less than 2 weeks) Fee: $ 10.00

5. Clerical Fee Fee: $ 25.00