mwcobgyn.com - Medical Records Transfer

Authorization Form for Release of Protected Health Information
Patient Name:
SSN:
DOB:

MonthDayYear
Date
Dr. Name:
Facility Requesting Information
Dr:
Facility:
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number:
Please enter a valid phone number.
Fax:
Facility with Disclosed Information
Dr:
Facility: Midland Women's Clinic
Address: 2500 W Illinois Ave Ste 100
State: TX Zip: 79701
City: Midland
Phone:432-699-2370 Fax: 432-697-3524
By signing this form, I authorize you to use and disclose the protected health information described below:

	YES	NO	CURRENT YEAR	DATES/ SPECIFICS
History & Physical Dr. Notes (rx, inj)
Lab
Pathology (pap, colpo, biopsies, etc)
Radiology (xray , MRI, U/S, mamo, etc)
Prenatal
Surgery (inpatient /outpatient)
Bone Density
ER Visit/ Hospital Stay

The information will be obtained, used, or disclosed for the following purpose(s):

InsuranceTreatment/ ReferralLegalTransferring care to other providerOther (specify):
I understand:
- I may revoke this authorization at any time by sending a written notification to the Privacy Officer at the above address. Unless revoked, the expiration date will be one year from the date of my signature.
- I release the entities listed above, their agents, and employees from any liability in connection with the use of disclosure of the protected health information covered by this authorization. The entity authorized to disclose the information will not be compensated by the recipient for the disclosure, except for the cost of copying and mailing as authorized by law.
- Information used or disclosed pursuant to this authorization may be subject to redisclosure by the recipient and no longer protected by federal law. However, the recipient may be prohibited from disclosing substance abuse information under the Federal Substance Abuse Confidentiality Requirements.
- I have the right to Inspect the health information to be released and I may refuse to sign this authorization.
- Unless the purpose of this authorization is to determine payment of a claim for benefits, the requesting entity will not condition the provision of treatment or payment for my care on my signing this authorization.
I understand that my medical information may indicate that I have a communicable or venereal disease which may include, but not limited to, diseases such as hepatitis, syphilis, gonorrhea, Chlamydia, or the human immunodeficiency virus, also known as HIV. I further understand that my medical information may indicate that I am or have been treated for psychological or psychiatric conditions of substance abuse.
Signature of Parent or Legal Representative

Clear
Date

MonthDayYear
Date
Description of Legal Representative's Authority
Expiration Date of Authorization

MonthDayYear
Date
NOTICE OF RIGHTS: Information in your medical record that have or may have a communicable or venereal disease is made confidential by law and cannot be disclosed without your permission except in limited circumstances including disclosure to persons who have had risk exposure, disclosure pursuant to an order of the court of the Department of Health, disclosure among healthcare providers or disclosure for statistical or epidemiological purposes. When such information is disclosed it cannot contain information from which you could de identified unless disclosure of that identifying information is authorized by you, by and order of court of the court of the Department of Health or by law.

***MEDICAL RECORDS REQUEST FOR MORE THAN 3 YEARS WILL BE A $25 DOLLAR CHARGE***
Should be Empty:

Authorization Form for Release of Protected Health Information

Facility Requesting Information

Facility with Disclosed Information