Release of Information Form

Authorization to Use and Disclose Protected Health Information
Patient Name*

First NameMiddle NameLast Name
Patient Birth Date*

MonthDayYear
Email
example@example.com
This medical record release form will apply to:

Self onlySelf and minor children
Names and Dates of birth of minor children (adults must complete their own form):
Patient Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Patient Phone Number

Area CodePhone Number
Patient Email Address
example@example.com
This authorization is to release the protected health information of the patient(s) named above from (check all that apply)*

Sunrise Family Practice
8785 S Jordan Valley Way Ste 100
West Jordan, UT 84088
Phone: 385-645-7474
FAX: 801-930-9073Revere Health or West Jordan Medical Center
1055 N 500 W
Provo UT 84604
Phone: 801-429-8062
FAX: 801-374-2615Other
Other, please provide provider name and/or facility name, and phone number:
Release Information To:

Beehive Comprehensive Clinic Inc.
3409 W 12600 S Ste 230
Riverton UT 84065
Phone: 801-252-6116
FAX: 801-508-2787
The following protected health care information will be released:*

Entire medical record (NOTE: This may include records from other health care providers, patient history forms, insurance information, correspondence, etc. It is NOT strictly limited to records generated by the physician/health care provider indicated above.) I understand that information disclosed pursuant to this authorization may include information relating to the following, unless specifically restricted below:
• Psychological/psychiatric conditions
• Drug and/or Alcohol abuse diagnosis and/or treatment
• HIV/AIDS diagnosis and/or testing
• Sexually transmitted disease(s) diagnosis and/or testing
• Genetic testing.ONLY the following specific information:
If the Entire Record is Not Released, Specify Type of Information to be Released
(List as specifically as possible, for example: name, dates of service, any documents).
Dates of Service FROM:*

MonthDayYear
Date (Estimate as needed)
TO:*

MonthDayYear
Date (Estimate or today's date)
Purpose of the Release of This Information

Continued Medical CareLegal PurposesDisability/Insurance Purposes/ClaimPersonal InterestOther, please specify
Release Date Expiration

MonthDayYear
Unless otherwise noted above, this authorization will remain in effect for one year from the date signed.
Consent*

• Once the provider/facility identified above discloses my health information by my request, it cannot guarantee that the Recipient will not re-disclose my health information to a third party. The third party may not be required to abide by this Authorization or applicable federal and state law governing the use and disclosure of my health information.
• Substance Use Disorder treatment records are protected by Federal Rule 42 CFR, part 2. Both a minor’s and a parent guardian’s signature must be obtained prior to disclosing the minor’s Substance Abuse Disorder records.
• I understand that my health record may include information related to my mental health, alcohol/substance abuse disorder, sexual assault, sexually transmitted diseases, abortion, genetic testing, HIV/AIDS, domestic violence, or other information I consider sensitive.
• I understand that: this release is valid when I sign it and I may refuse to sign or may revoke this Authorization at any time for any reason and that such refusal or revocation will not affect the commencement, continuation or quality of this provider's or facility's treatment of me, enrollment in the health plan, or eligibility for benefits.
Signature*

Clear
Name of person signing:*

First NameMiddle NameLast Name
Relationship to Patient*
Date Signed

MonthDayYear
Date
Should be Empty:

Authorization to Use and Disclose Protected Health Information