Authorization for Release of Health Info

AUTHORIZATION

Patient Authorization for Disclosure of Health Information
Patient Name
Date of Birth

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Phone Number
Please enter a valid phone number.
I request that my Protected Health Information (PHI) fromDoctor name, address, phone#, fax #) be disclosed to"
Recipient Name
Recipient Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Recipient Email
example@example.com
Recipient Phone Number
Please enter a valid phone number.
Recipient Fax
Please enter a valid phone number.
I authorize the following PHI to be released from my medical record(s):

Emergency Room RecordLaboratory Report(s)Radiology Report(s)Pathology ReportCardiology Report(s)Immunization RecordProvider Office VisitCornerstone CounselingAny and All RecordsAbstract/Summary (Includes Discharge Summary, History & Physical, Operative Report(s), Consultations and Test Result(s).Test Result(s) of:Radiology film/imaging studies/tracing/mediaItemized Billing RecordsOther
Please list the specific Test Results
I understand that the information in my health record may include information relating to sexually transmitted disease (STD), Acquired immunodeficiency virus (HIV). It may also include information about behavioral or mental health services and treatment of alcohol or drug abuse.

State and federal law protect the following information. If this information applies to you, please indicate if you would like this information released/obtained (include dates where appropriate)

	Yes	No	Dates
Alcohol, Drug or Substance Abuse Records
HIV Testing and Results
Mental Health
Psychotherapy Records

Covering the period of healthcare from: Specific Date(s): Date to Date .
Purpose of requesting information:

LegalInsurancePersonalContinuation of CareOther (Please specify on line below)
Disclosure Format (Paper is default if not marked)

US MailIn-Person Pick-upFaxE-mail (Secure Format with Encryption)E-mail (Unsecure Format, i.e. Gmail, Yahoo)CD (Radiology Images Only)Flash Drive - Secure FormatOther (Please Specify Below)
By signing this authorization form, I understand that:
- Requests for copies of medical records are subject to reproduction fees in accordance with federal/state
  guidelines.
- I have the right to revoke this Authorization at any time. Revocation must be made in writing and presented
  or mailed to the Health Information Management Department at the following address: 422 W. White St.,
  Clinton, IL 61727. Revocation will not apply to information that has already been disclosed in response to
  this Authorization.
- Unless otherwise revoked, this Authorization will expire on the following date/event/condition:
  - If I fail to specify an expiration date/event/condition, this Authorization will expire 90 DAYS from the
    date signed.
  - Treatment, payment, enrollment or eligibility for benefits may not be conditioned on whether I sign this
    Authorization.
  - Any disclosure of information carries with it the potential for unauthorized redisclosure and the information
    may not be protected by federal confidentiality rules.
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AUTHORIZATION