Request Your Records from MPH

AUTHORIZATION FOR THE DISCLOSURE OF HEALTH INFORMATION -

RELEASING RECORDS FROM MPH TO AN INDIVIDUAL OR OTHER AGENCY
Federal law says that we cannot share your health information without your permission, except in certain situations. If you sign this form, you are giving us permission to share the health information you indicate below. This does not prevent the information from being re-shared by the recipients.

Please complete the following information for the request of release of records from MPH.

If you need help with this form, please call 406-258-3363.
Client Name:*

First NameLast Name
Other Names Used: (maiden name, previous name, etc.)

First NameLast Name
Client Date of Birth: *

MonthDayYear
The purpose of this records request is (please select one):*

Coordination/Continuity of Care (ex. ongoing appts/visit summaries/updated care plans, etc.)Client RequestOther
I am requesting the following Protected Health Information to be released from MPH (please check all that apply):*

Immunization Records (this includes immunization records recorded in imMTrax)Travel Clinic RecordsTuberculosis Screening/TreatmentLaboratory ResultsHome Visiting RecordsDiabetes Prevention Program RecordsRD / Nutrition RecordsOther
Specific Date(s): Date to Date
Specific Information only: please specify
Please release the selected Protected Health Information:*

I will pick in person up at Missoula Public Health (301 W. Alder St.)USPS MailFaxEmailI would like it sent to another Health Provider / Clinic / Care CenterOther
Please provide necessary recipient information below:
Individual/Organization:

First NameLast Name
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Fax Number
Please enter a valid phone number.
Email address to send encrypted email:

Confirmation Emailexample@example.com
Please provide a phone number where we can reach you with any questions about this form: *
Please enter a valid phone number.
Please upload a copy or photo of your government-issued ID card: (Ex: Driver's License)*

Cancelof
Please provide an email address below if you would like a signed copy of this completed form sent to you:

Confirmation Emailexample@example.com
Unless otherwise revoked, this authorization will expire one year after it is signed. By signing this authorization, I acknowledge that:
- My record may contain information regarding the screening for HIV (human immunodeficiency virus), other bloodborne pathogens (Hepatitis B, Hepatitis C), or sexually transmitted diseases. I give my specific authorization for these records to be released.
- Only records maintained by the Missoula City-County Health Department (MPH) will be released.
- With this request on file, immunization records from the State Registry imMTrax, also can be released.
- I have the right to revoke this authorization at any time. Revocation must be done in writing. I understand that I cannot revoke an authorization for information that has already been released in response to this authorization.
- This authorization is voluntary. I can refuse to sign this authorization. I need not sign this authorization to receive treatment. Refusing to sign this authorization will not affect payment for services, enrollment, or eligibility for benefits.
- I may inspect or copy this authorization provided in 45 CFR 164.524. I understand that any disclosure of information under this authorization carries with it the potential for an unauthorized re-disclosure by the recipient and, after it is disclosed, the information may not be protected by state or federal confidentiality rules. If I have questions about disclosure of my health information, I can contact the Missoula City-County Health Department (MPH) Health Services Division Director at (406)258-4986.
Client / Authorized Representative* Signature*

Clear
By signing this form, I agree that the information I provided is accurate and truthful, and I agree with the acknowledgement and consent above.

*Parent, Legal Guardian, or Legal Representative. Supporting legal documentation must accompany this form when services are requested by the client's Legal Guardian or Legal Representative.
Printed name of person signing/requestor: *

First NameLast Name
Relationship of requestor to client:*

SelfParentLegal GuardianPower of AttorneyOther
Please upload proof of relationship, if applicable (Ex: Power of Attorney)

Cancelof
Please verify that you are human*
Should be Empty:

Please provide necessary recipient information below: