This is an Authorization form that will permit information in your medical record to be electronically shared with SHIFT. Please read it carefully. Your Health Information will NOT be shared with your employer without your prior authorization.
Health information to be disclosed:
All information contained in your electronic medical record will be disclosed. This includes but is not limited to diagnostic test results, problem list, medication list, allergy list, certain sensitive categories of health information such as mental health records, alcohol/substance abuse treatment records, HIV/AIDS test results, and genetic test results. By signing this Authorization, you grant permission to disclose even these sensitive categories of health information for the purposes set forth in this form.
Purpose of the disclosure: [Treatment and continuity of care at the request of the patient or patient's legal representative.]
Your decision to sign this form and authorize the disclosure of your medical information is completely voluntary and you may refuse to sign this form. If you do not sign this form, the information will not be released. The Authorizing Institution will not deny or condition your health care treatment or payment for services, upon signing this form.
This Authorization expires when the treatment and related services for your current visit are complete. If you wish you may cancel this Authorization at any time by sending a written request to your Authorizing Healthcare Provider, but this will not change releases that were made before the cancellation. Once your information has been disclosed, it may potentially be re-disclosed and the disclosed information may not be covered by federal or state privacy protections. Once your information is disclosed to SHIFT it will be used and maintained according to that organization's policies and practices. You have a right to inspect and copy the information to be disclosed. You are entitled to a copy of this Authorization and you may also view a copy of your Authorizing Healthcare Provider's Notice of Privacy Practices at any time be viewing your Authorizing Healthcare Provider's website or by contacting your Authorizing Healthcare Provider's registration department.
Record is to be released from the following individual/organization: