Release of Health Care Information

Release of Health Care Information

Please notify practice when this form is complete
Patient Name (last, first)*
Date of birth*

MonthDayYear
Date
Contact email (patient or guardian)*
example@example.com
I hearby authorize Greenlake Primary Care to release health information (choose one or both)

TO the following partyFROM the following party
Name of other person/provider*
Office/Organization
Email (if known)
example@example.com
Telephone
Format: (000) 000-0000.
Fax (if known)
This request is

Urgent (same day)Routine (up to 2 days)
The following information should be released (may choose multiple items)*

All health information in my medical recordConversation or coordination between health care providersSpecific information related to a condition/date/test/or bill
I DO NOT wish the following information to be shared

HIV/AIDS related informationSexually transmitted diseasesMental health care or treatmentDrug and/or alcohol use
I authorize the above parties to communicate via email about my medical and psychiatric care. (optional)

Yes
Reason for request*

At my request/coordination of careOther
Date or situation release ends*
I understand that I may inspect or copy the protected health information to be disclosed, that I may revoke this authorization in writing by contacting either of the above offices, and that information disclosed pursuant to this authorization my be subject to re-disclosure by the recipient and may no longer be protected by HIPPA.

I understand I may refuse to sign this authorization and that you will not condition treatment, payment or enrollment. However, I do need to sign to take part in a research study, for research-related treatment and to receive health care when the purpose is to create health care information for a third party.
Patient or legal guardian*
Date

MonthDayYear
Date
Printed name if guardian
Relationship
Should be Empty: