Blue Ridge Medical Center

AUTHORIZATION TO RELEASE OR OBTAIN MEDICAL, BEHAVIORAL, AND DENTAL PROTECTED HEALTH INFORMATION

I understand that different agencies provide different services and benefits. Each agency must have specific information in order to provide services and benefits. By signing this form, I am allowing agencies to exchange certain information so it will be easier for them to work together effectively to provide and coordinate these services or benefits.

A SEPARATE FORM must be completed for EACH PROVIDER with whom you are requesting records be exchanged!

Facility releasing/obtaining protected health information

Release/Obtain Protected Health Information for the following dates:

Unless the format of records is indicated specifically above, the above information may be shared verbally, or in written or electronic form. I understand that information disclosed pursuant to this authorization may be released or distributed by the recipient and may no longer be protected by HIPAA. Sensitive records, such as those related to mental health, alcohol abuse or substance abuse treatment, HIV/STDs may be included in the release of records/information. Except to the extent that Blue Ridge Medical Center or other lawful holder of my records has already acted in reliance upon it, this authorization is subject to revocation at any time by sending a written request to Blue Ridge Medical Center, Release of Information, Attn: Privacy Officer, 4038 Thomas Nelson Hwy, Arrington VA 22922. Otherwise, this authorization will automatically expire within one year of the signed date below.

As the person signing this authorization, I understand that I am giving my permission to the above-named health care entity for disclosure of confidential health records. A copy of this authorization and a notification concerning the person or agencies to whom disclosure was made shall be included with my original health record. I may refuse to sign this form. I understand that Blue Ridge Medical Center will not condition the provision of treatment, payment, enrollment in a health plan, or eligibility for benefits on the provision of this authorization.

NOTICE TO RECIPIENT OF RECORDS: The information has been disclosure to you from records protected by Federal Regulations (42 CFR Part 2) which prohibits a recipient from making any further disclosure of this  information in this record that identifies a patient as having had a alcohol or substance use disorder either directly, by reference to publicly available information, or though verification of such identification by another person unless further disclosure is expressly permitted by the written consent of the individual whose information is being disclosed or as otherwise permitted by 42 CFR Part 2. A general authorization for the release of medical or other information is NOT sufficient for this purpose (see 2.31). The federal rules restrict any use of the information to investigate or prosecute with regard to a crime any patient with a substance use disorder, except as provided at #2.21© (5) and 2.65.