Authorization for the Disclosure of Health Information *Updated*

Authorization for the Disclosure of Health Information (Release of Records)
This form is to be used for record requests for: Flathead City-County Health Department Immunization Clinic and immunization records from the Montana immunization database (Immtrax).

Federal law says that we cannot share your health information without your permission. If you sign and submit this form, you are giving us permission to share the health information you indicate below. This does not prevent the information from being re-shared by the recipients.

- One authorization form per records request.

- Future requests will require a new records release form.

- Incomplete authorization forms will not be processed.
Patient Information
I am requesting the release of this information:*

For myselfOn behalf of someone else
Reason for Request*
Relationship to person whom you are requesting record on behalf of (e.g. parent of minor child)*
Name*

First NameLast Name
Other Name(s) Used

First NameLast Name
Your Name*

First NameLast Name
Your Phone Number*
Please enter a valid phone number.
Patient's Name*

First NameLast Name
Other Name(s) Used

First NameLast Name
Patient's Date of Birth*

MonthDayYear
Date
Date of Birth*

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.
Submit a copy of a valid ID (i.e. drivers license, state issued ID card, etc.)*

Cancelof
Additional Documentation (Optional)

Some requests may require additional documentation. For example, an adult requesting records for their elderly parent will need to provide proof of power of attorney. Please attach any such additional documentation here.
Cancelof
Request Information

Select the type of information that you would like released and where you would like the information sent.
Select the following information you would like to be sent (mark all that apply)*

Immunization recordsTB screening/TB treatmentLab recordsOther
Select the date range for records you are requesting:*

All available records for all dates of serviceRecords from specific dates of service: (mm/dd/yyyy to mm/dd/yyyy)
Please enter specific range of dates of service: (mm/dd/yyyy to mm/dd/yyyy)
Send By:*

MailFaxEmail (Secured HIPAA Compliant)Pick up at Health Department
When authorizing an individual to pick up a record on your behalf at Flathead City-County Health Department, please ensure that the name provided matches the individual's photo ID.

Individuals will not be able to pick up copies of records without a matching photo ID.

A staff member will call the person picking up the record to let them know when the records are ready for pick up.

Pick up location is: Flathead City-County Health Department, 1035 1st Ave W, Kalispell, MT 59901 in Suite 110.
Name of individual picking up record at Health Department*

First NameLast Name
Phone Number of individual picking up record at Health Department*
Please enter a valid phone number.
Name of recipient*
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Fax Number*
Please enter a valid fax number.
Email*
example@example.com
By signing this authorization, I acknowledge that…

• With written consent on file, only records maintained by Flathead City-County Health Department and the State Registry imMTrax will be released.

• I have the right to revoke this authorization at any time. Revocation must be done in writing. I understand that I cannot revoke an authorization for information that has already been released in response to this authorization.

• This authorization is voluntary. I can refuse to sign this authorization. I need not sign this authorization to receive treatment, payment for services, enrollment, or eligibility for benefits.

• I may inspect or copy this authorization provided in 45 CFR 164.524. I understand that any disclosure of information under this authorization carries with it the potential for an unauthorized re-disclosure by the recipient and, after it is disclosed, the information may not be protected by state or federal confidentiality rules.
NOTICE:*

I have read and understand the above statement.
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Authorization for the Disclosure of Health Information (Release of Records)

Patient Information

Request Information