Release of Information Form

Patient Name *

First Name Middle Name Last Name

Patient Birth Date *

Month Day Year

Email

example@example.com

This medical record release form will apply to:

Self only Self 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

City State / Province

Postal / Zip Code

Patient Phone Number

Area Code Phone 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: 801-930-9073 Revere Health or West Jordan Medical Center
1055 N 500 W
Provo UT 84604
Phone: 801-429-8062
FAX: 801-374-2615 Other

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: *

Date (Estimate as needed)

TO: *

Date (Estimate or today's date)

Purpose of the Release of This Information

Continued Medical Care Legal Purposes Disability/Insurance Purposes/Claim Personal Interest Other, please specify

Release Date Expiration

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 Name Middle Name Last Name

Relationship to Patient *

Date Signed

Date

Authorization to Use and Disclose Protected Health Information