Request Authorization for Disclosure of Personal Health Information

Please complete all sections that apply completely to ensure timeliness in processing.
Name
Address
City/State/Zip
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Maiden/Prior Name
Social Security Number
Birthdate

MonthDayYear
Date
Provider who has your medical information
Provider Name/Facility
Address
City/State/Zip
Phone
Format: (000) 000-0000.
Fax
Please enter a valid phone number.Format: (000) 000-0000.
Give information to:
Name/Facility
Address
City/State/Zip
Phone
Format: (000) 000-0000.
Fax
Format: (000) 000-0000.
Mammography Films
Records to be released

Other
Records to be released by:
Email
example@example.com
Please send my email
Limit Records to:
Time period from:

MonthDayYear
Date
To:

MonthDayYear
Date
Expiration Date: This authorization will expire one year from the date of signature or on:

MonthDayYear
Date
Concerning specific diagnosis or treatment of:

0/35
Revocation

I understand that I may revoke this authorization at any time by sending written notice to the health care facility/provider noted above. I understand that any release of information made prior to my revocation in compliance with this authorization shall not constitute a breach of my rights to privacy.
Authorization

I hereby authorize the above facility/provider to disclose medical information concerning the above named patient to the party identified in the section entitled "Disclose Information To". I understand that the information to be released may include information regarding treatment of mental health, alcohol and drug usage, HIV (human immunodeficiency virus), AIDS (acquired immunodeficiency syndrome) related information. I understand that once the information is disclosed, it may be subject to re-disclosure by the recipient and may no longer be protected. I further understand that I may refuse to sign this authorization and that my refusal will not affect my ability to obtain treatment or payment or my eligibility for benefits.
Signature of Patient or Representative
**If signed by representative, please state authority to act on behalf of the patient.

I understand I am not required to sign this authorization if I do not wish to release my records

*A photocopy/fax of this authorization will be treated in the same manner as an original*

** Grand River Health - HIM/Medical Records Department: Fax #970-625-2752 Phone #970-625-6412 **
Commments

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Initial
Should be Empty:

Provider who has your medical information

Give information to:

Limit Records to:

Revocation

Authorization