Authorization for Release of Protected Health Information

Authorization for Release of Protected Health Information
Received from: Nurse Practitioner Services of Michiana Street Address 55756 Reeves Dr City IN 46514

Send to (NPS will complete) blank Street Address Address Line 2 City State Zip
Complete Medical RecordsEmergency Room NoteHospital Discharge SummaryConsultationsHistory and Physical ExaminationsRecords from Other Providers (please specify information below)X-Ray, Imaging ReportsLaboratory ReportsCardiac/EKG ReportsOther (please specify below)
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Continuing CareRelocationInsuranceLegalOther please specify
Type a question
I understand that I have no obligation to disclose information from my record and that I may revoke this authorization by submitting a request in writing along with a copy of this form to the practice manager of this office. I understand that any action already taken in reliance on this authorization cannot be reversed in my revocation will not affect those actions. The signing of this authorization is not a condition for providing treatment. I understand that if the organization authorized to receive information is not a health plan or healthcare provider, the information may be redisclosed and the longer be protected by Federal privacy regulations. However, certain protected health records such as drug and/or alcohol use, abuse treatment, or referrals for treatment; HIV information; and mental health services may not be redisclosed per Indiana state laws and regulations and or Federal confidentiality rules.
HIV information;Mental health services;Drug and/or alcohol use, abuse, treatment, or referrals for treatment.
My signature also acknowledges receiving a copy of the document.

THIS AUTHORIZATION SHALL EXPIRE 12 MONTHS FROM THE DATE EXECUTED UNLESS OTHERWISE SPECIFIED BY THE PATIENT:
Print Patient's full name
Relationship to Patient
Signature of Patient/Responsible Party

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Today's Date

MonthDayYear
Date
Patient's Date of Birth

MonthDayYear
Date
Patient's Social Security Number
Witness Signature

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Date

MonthDayYear
Date
Patient Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
NOTE: THIS AUTHORIZATION WILL NOT BE ACCEPTED UNLESS IT IS COMPLETED IN ITS ENTIRETY. A COPY OF THIS FORM WILL BE ACCEPTED IN LIEU OF AN ORIGINAL. A COPY OF THIS AUTHORIZATION IS TO BE GIVEN TO THE PATIENT OR PATIENT REPRESENTATIVE.
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