Medical Records - Authorization for Release of Protected Health Information

Medical Records - Authorization for Release of Protected Health Information (PHI)
Patient Information

Please complete this section with the name and contact information that your provider would have on file.
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth *

MonthDayYear
Date
Primary Phone Number*
Please enter a valid phone number.
Last 4 digits of the patient's social security number
Requester Information

The contact information for the person or organization that the records should be sent to:
Relationship to Patient*
Name*

First NameLast Name
Organization Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Requester Phone Number*
Please enter a valid phone number.
Requester Fax Number*
Please enter a valid phone number.
Email*
example@example.com
Release of Information
Authorization Expires on Date*

MonthDayYear
Please specify the date on which this authorization to release records expires. Note: This authorization automatically expires one year from the original date.
Reason for Disclosure*

Continuation of Care/Transfer of CareWorkman's CompensationAttorney/LegalInsurance CompanyRelocationOther
Delivery Method*

Mail (Per package delivery cost)Fax (Per package delivery cost)Pick up in person from office
Document Types Requested*

All PHI in the Medical RecordsX- Ray Test/ReportsConsultation ReportsItemized Billing StatementLab ReportsPatient Information FormHistory and Physical ReportsProgress NotesDischarge SummaryOther
From Date of Service*

MonthDayYear
Date
To Date of Service *

MonthDayYear
Date
Comments and Exclusions
Exclude Information
Select any sensitive information that, if available, you do not authorize us to release. If no information is selected you authorize us to release any and all information in your file.
Comments
Identity Verification
File Upload*

A copy of the patient's driver's license or other valid documentation (such as patient release documentation, letter of representation, etc.) is required for processing. Note: If patient is deceased, a copy of the patient’s death certificate must be submitted to medical records so it can be added to the patient’s chart.
Cancelof
Authorization
I understand the information be released, which may include: alcohol and drug abuse/treatment; physical and social work counseling; HIV, AIDS, or ARC; communicable disease or infection, including sexually transmitted diseases, venereal disease, tuberculosis and hepatitis; genetic information and demographic information, for the purposes and conditions designated on this form.

I understand that Baton Rouge Cardiology Center is not responsible for any subsequent disclosure of protected health information as a result of providing this information to the above-mentioned parties.

I further understand that I am not required to disclose to Baton Rouge Cardiology Center the reason for this request and that I may subsequently revoke this request if necessary.
I understand that I may refuse to sign this authorization and that it is strictly voluntary. If I do not sign this form, my health care and the payment for my health care will not be affected unless stated otherwise.

I understand that I have the right to revoke this authorization at any time in writing and must present the written revocation to the provider authorized to release the protected health information. I understand if I do revoke this authorization it will not apply to information that has already been released to this authorization. If the requester or receiver is not a health plan or health care provider, the released information may no longer be protected by federal privacy regulations and may be re-disclosed.
Legible Signature Required*

Clear
Should be Empty:

Medical Records - Authorization for Release of Protected Health Information (PHI)

Patient Information

Requester Information

Release of Information

Comments and Exclusions

Identity Verification

Authorization