One TeleMed - Authorization to Release or Obtain Health Information

Louisiana Department of Health and Hospitals

Authorization to Release or Obtain Health Information (including paper, oral and electronic information) Request Date:
Client Name*
Date of Birth*

MonthDayYear
Date
Request Date*

MonthDayYear
Date
Medicaid # or Social Security #*
Mailing Address*
City/State/Zip*
I AUTHORIZE :
Name of Person/Company*
Telephone Number
Mailing Address*
City, State, Zip Code*
Relationship to Client/ Company*
( Place and "X" in the box that indicates if the information is being released OR requested)*

TO RELEASE information TOTo OBTAIN information FROM
Name of Person/Company*
Mailing Address Of Organization*
City, State, Zip Code*
Relationship*
Telephone Number*
I authorize the release of the following protected health information. Place an "X" in the boxes that apply to the information you want released or you want to obtain*

Entire RecordPrescriptionsX-ray ReportsSurgical ReportsTreatment or TestsMedical History, Examination, Reports ImmunizationsMR/DD RecordsLaboratory ReportsOther
The Purpose of this Authorization is indicated in the boxes below. (Place an "X" in the boxes that apply.)*

Further Medical CarePersonalLegal Investigation or ActionChanging PhysiciansResearch related treatmentCreating health information for disclosure to a third party.Other
In compliance with state and/ or federal laws which require special permission to release otherwise privileged information , please release the following records.

AlcoholismDrug AbuseMental HealthVocational RehabilitationPsychotherapy NotesHIV (AIDS)Sexually Transmitted DiseasesGeneticsOther
I understand that if I do not specify an expiration date, this authorization will expire six (6) months from the date on which it was signed. I acknowledge that I have read both pages 1 and 2 of this form.
Signature of Individual or Personal Representative Authorized by Law*

Clear
Signature of Witness (If signed with an "X" or mark)

Clear
For DHH Use When Requesting Records

I am authorized to receive this disclosure. Documentation on the above Personal Representative has been obtained.
Should be Empty: