Release of Confidential Information

AUTHORIZATION TO RELEASE MEDICAL RECORDS
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Last 4 SSN*
INFORMATION TO BE RELEASE FROM (FACILITY OR PROVIDER)
Name of Facility or Provider*
Street / Mailing Address of Facility or Provider *
City*
State*
Zip Code*
INFORMATION TO BE SENT TO:*
How is the information to be sent:*
INFORMATION TO BE RELEASED:*

The most recent two (2) years of pertinent information (chart notes, labs, x-rays, special tests)ALL Medical Records (regardless of date)ALL Medical Records (specific date range)Specific Information:
If ALL Medical Records (specific date range), indicate it here:*
If Specific Information, indicate it here:*
PURPOSE FOR WHICH THE DISCLOSURE IS BEING MADE (Check One)*

AttorneyInsuranceDoctorPersonal
PATIENT AUTHORIZATION:

I understand that my records may contain information regarding the diagnosis or treatment of HIV/AIDS, sexually transmitted diseases, drug and/or alcohol abuse, mental illness, or psychiatric treatment. I give my specific authorization for these records to be released.
EXCLUDE the following information from the records released (please initial):*

Drug abuse / treatment & diagnosisHIV diagnosis / treatment / testing (Positive Results only)Alcohol abuse / treatment & diagnosisSickle Cell Anemia (Positive Results Only)
MY RIGHTS:
I understand that I do not have to sign this authorization in order to obtain health care benefits (treatment, payment, or enrollment). I may revoke this authorization in writing. To view the process for revoking this information, please read the Privacy Notice to Patients posted at the facility where your information is being released. I understand that once the health information I have authorized to be disclosed reaches the noted recipient, that person or organization may re-disclose it, at which time it may no longer be protected under Privacy laws.
Signature of Patient or Authorized Representative

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Date Signed

MonthDayYear
Date
THIS AUTHORIZATION WILL EXPIRE 90 DAYS FROM THE DATE SIGNED
I First Name Last Name, hereby authorize Atlanta Telehealth, LLC,
to:*

Release of InformationReceive Information
Information to be disclosed:

Psychiatric AssessmentMedication Records
Purpose of disclosure:

Continuity of CareLegal PurposesPersonal UseOther
Recipient of Information:
Name/Organization:
Address:
Phone Number:
FAX Number
Case ID (if applicable)
Expiration of Authorization:
This authorization will expire on 90 days from the date of signature
I understand that:

I may revoke this authorization at any time by providing written notice to Atlanta Telehealth, LLC, except to the extent that information has already been disclosed based on this authorization.The information disclosed may be subject to redisclosure by the recipient and may no longer be protected by federal or state privacy regulations.This authorization is voluntary, and I may refuse to sign it without affecting my treatment, payment, or eligibility for benefits.A copy of this form is as valid as the original.
Acknowledgement
- I may revoke this authorization at any time by providing written notice to Atlanta Telehealth, LLC, except to the extent that information has already been disclosed based on this authorization.
- The information disclosed may be subject to redisclosure by the recipient and may no longer be protected by federal or state privacy regulations.
- This authorization is voluntary, and I may refuse to sign it without affecting my treatment, payment, or eligibility for benefits.
- A copy of this form is as valid as the original.
Name

First NameLast Name
Signature

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Date

MonthDayYear
Should be Empty:

AUTHORIZATION TO RELEASE MEDICAL RECORDS