Floyd Authorization for Release of Protected Health Information

Authorization for Release of Protected Health Information
Name

First NameMiddle NameLast Name
Maiden Name or Other Name
Date of Birth

MonthDayYear
Date
Social Security Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone Number
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Cell Phone Number
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I hereby authorize the following provider to release my file as indicated below to Tri-Area Community Health, P.O. Box 9, Laurel Fork, Virginia 24352. Phone: 276-398-2292 Fax: 276-398-3331
I hereby authorize Tri-Area Community Health to release information from my medical record as indicated below to:
Provider Information (Name, address, and phone number)
Information to be released
ALLBilling SummariesHistory and Physical ExamImmunizationsLab ReportsProgress NotesXRay Reports
Please list the dates of records to release (from/to)
Dates
Continuation/Coordination of Care, follow-up treatment or ongoing careChanging ProvidersDisability DeterminationOther
Substance abuse (including alcohol/drug abouse)Mental Health/Behavioral Health Therapy NotesHIV related information (AIDS related testing
Signature

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Authorization
· I understand this authorization will expire in 1 year after I have signed this form.

· I understand I may revoke this authorization at any time by notifying the providing organization in writing, and the revocation will be effective on the date notified except to the extent action has already been taken.

· I understand that I am giving my permission to the above-named provider or othernamed third party for discloure of confidential health records. I further understand that TACH cannot condition the provision of treatmentto me on my signing of this authorization.

· A copy of this consent and a notation concerning the persons or agencies to which disclosure was made shall be included with my original records. The person who receives the records to which this consent pertains may not redisclose them to anyone else without my separate written consent unless the recipient is a provider who makes a disclosure permitted by law. There is a potential for any information disclosed pursuant to this authorization to be subject to re-disclosure by the recipient and, therefore, no longer protected by the provisions of the HIPAA policy rule.
Signature

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Date

MonthDayYear
Date
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Authorization for Release of Protected Health Information

Information to be released

Authorization