Authorization for the Disclosure of Health Information to Oneself

Authorization for the Disclosure of Health Information

Federal law says that we cannot share your health information without your permission except in certain situations. If you sign and submit 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. Records requests expire 30 days after the date the requestor authorized and signed the release form. One authorization form per immunization records request. Future requests will require a new records release form. Incomplete authorization forms will not be processed.
Patient Information
Name*

First NameLast Name
Other Name(s) Used (maiden or previous married name)

First NameLast Name
Date of Birth*

MonthDayYear
Date
MaleFemale
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Submit a copy of a valid ID (i.e. drivers license, state issued ID card, etc.)*

Cancelof
Request Information

Please enter information regarding what kind of information you would like to be released, and where you would like the health information to be sent.
MailFaxEmail (Secured HIPAA Compliant)
For Specific Dates (mm/dd/yyyy to mm/dd/yyyy)*
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Progress notesTB screening/ TB treatmentBreast examPap smearRadiology reportsLab recordsHIV related information (testing)Immunization recordsSpecialistOther
(FROM) Requestor Information

Please enter information regarding who is requesting the information.
For myselfOn behalf of someone else
Requestor Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Relationship to Patient
Reason for Request*
By signing this authorization, I acknowledge that…

• With written consent on file, only records maintained by Flathead City-County Health Department and the State Registry imMTrax will 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, 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.
I have read and understand the above statement.
Signature*
Date*

MonthDayYear
Date
Client/Authorized Representative Signature*
Date*

MonthDayYear
Date
Should be Empty:

Authorization for the Disclosure of Health Information

Patient Information

Request Information

(FROM) Requestor Information