Release of Health Information Form (IPM BHI) Incoming Form (002)

Release of Health Information Incoming Form

Basic Home Infusion & Implanted Pump Management

Use this form when you would like an outside facility or provider to send us your records (i.e. doctor's office or hospital)

Patient Name*

Street Address*

City/State/Zip Code:*

Date of Birth*

Date

Email Address

example@example.com

Telephone Number*

I authorize the following facility or provider to disclose verbally or in writing, individually identifiable health information about me to:

Basic Home Infusion/Implanted Pump Management

1401 Valley Road

Wayne, NJ 07470

201-475-0500

ATTN: Medical Records

Name of facility/provider:*

Address of facility/provider*

City*

State*

Zip Code*

Phone Number

Specific Information requested from facility/provider:

All health informationRecord of telemetries only

Information to be used for the purpose of:

Continuing medical treatmentAttorneyInsuranceOther

This authorization shall expire 12 months from the date of the request. This authorization may be revoked by me at any time by a written or verbal notice to BHI/IPM, except to the extent that BHI/IPM has relied on the authorization.

BHI/IPM will not condition treatment, payment, enrollment or eligibility for benefits on whether I sign this authorization.

I further understand specific type of information to be disclosed may, if applicable include: Psychological Treatment, Diagnosis, Prognosis and treatment for Acquired Immune Deficiency Syndrome, Aids Related Complex, or Human Immunodeficiency infection for any date of service.

Signature of Patient or Authorized Person*

Date*

Date

Relationship of Authorized Person