Galax Highlands Records Release From

Authorization for Release of Protected Health Information
Name

First NameMiddle NameLast Name
Date of Birth

MonthDayYear
Date
Social Security Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
What is the purpose of this release?

Continuation/Coordination of CareFollow-up TreatmentOn-going CareOther
I hereby authorize the following provider to release my file 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:
Information to be Released
Choose all that apply:

History and Physical ExamProgress NotesLab ResultsX-Ray ResultsOther _____________________________________________
Please list the dates of records to release (from/to)
Dates
Specifically authorize the release of information related to: (please sign authorization below for this section only)

Substance abuse (including alcohol/drug abuse)Mental Health (including psychotherapy notes)HIV related information (AIDS related testing)
Signature
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 information used or disclosed pursuant to this authorization may be subject to redisclosure by the recipient and no longer be protected by Federal privacy regulations

· I understand that while there is usually no charge for medical records if copies are sent for ongoing care or follow up treatment, some facilities charge for transfer of records. The patient is responsible for any charges related to the transfer of records.
Signature
Date

MonthDayYear
Date
Should be Empty:

Authorization for Release of Protected Health Information

Information to be Released

Authorization