ONECORE HEALTH RELEASE OF INFORMATION

Full Patient Name:*

Medical Record Number:

If known- if not, leave blank.

Date of Birth:*

Date

Social Security Number:*

I hereby authorize what organization to disclose PHI:

I hereby authorize OneCore Health to release the following information to:*

Self or name of person/organization receiving PHI

Please list phone number for us to call you with any questions:*

Please enter a valid phone number.

How would you like to receive your medical records?*

FaxMailPick Up

Fax Number (Including Area Code)

Mailing Address

	Address
Street Address
City
State
Zip Code

Information to be shared:*

Entire Medical RecordBilling informationMedical information for specific dates (list dates below)Other

Medical information compiled between what dates:

MM/DD/YYYY to MM/DD/YYYY

This information may be disclosed for the following purpose(s) only:*

I understand that by voluntarily signing this authorization:

I authorize the use or disclosure of my PHI as described above for the purpose(s) listed.
I have the right to withdraw permission for the release of my information. If I sign this authorization to use or disclose information, I can revoke this authorization at any time. The revocation must be made in writing to the person/organization disclosing the information and will not affect information that has already been used or disclosed.
I have the right to receive a copy of this authorization.
I understand that unless the purpose of this authorization is to determine payment of a claim for benefits, signing this authorization will not affect my eligibility for benefits, treatment, enrollment or payment of claims.
My medical information may indicate that I have a communicable and/or non-communicable disease which may include, but is not limited to diseases such as hepatitis, syphilis, gonorrhea or HIV or AIDS and/or may indicate that I have or have been treated for psychological or psychiatric conditions or substance abuse.
I understand I may change this authorization at any time by writing to the person/organization disclosing my PHI.
I understand I cannot restrict information that may have already been shared based on this authorization.
Information used or disclosed pursuant to the authorization may be subject to redisclosure by the recipient and no longer be protected by the Privacy Regulation.

Unless revoked or otherwise indicated, this authorization’s automatic expiration date will be one year from the date of my signature or upon the occurrence of the following event:

List specific event if indicated, otherwise leave blank

Signature of Patient or Legal Representative*

Date Signed*

Date

Description of Legal Representative’s Authority

If indicated, otherwise leave blank

Copy of Photo ID*