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

Release of Health Information Outgoing Form

Basic Home Infusion & Implanted Pump Management

Use this form when requesting BHI/IPM send your records to another provider/individual or facility

Patient Name*

Date of Birth*

Date

Street Address*

Email Address

example@example.com

City/State/Zip Code*

Telephone Number*

I authorize Basic Home Infusion, LLC/Implanted Pump Management to disclose verbally or in writing, individually identifiable health information about me or the patient as listed above to the following:

Name of Authorized Person/Provider*

Email of Authorized Person/Provider

example@example.com

Address of Authorized Person/Provider*

Check here if you want BHI/IPM to email your medical record to you or your provider in a secure manner:

Yes, please email

City

State

Zip Code

Phone Number

Specific Information requested:

All Health InformationRecord of Telemetries only

Information to be used for the purpose of:

Continuing medical treatmentAttorneyInsuranceOther

Please check if information can be left on an answering machine

YesNo

If you answered "Yes" please put in Phone number

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 Basic Home Infusion, LLC/ Implanted Pump Management, except to the extent that Basic Home Infusion, LLC/ Implanted Pump Management, has relied on the authorization

Signature of Patient or Authorized Person*

Date*

Date

Relationship to authorized person