Authorization to Disclose Protected Health Information (Clinics)

Authorization to Disclose Protected Health Information
The purpose of this request is to share protected patient information with another Healthcare entity for the purpose of continued treatment. An abstract of the last year will be provided unless otherwise specified. Medical records will be faxed or emailed only to verified valid recipients. You may be contacted by the telephone number provided for further clarification and validation.

The undersigned authorizes Covington County Hospital and Clinics to release my health information as noted below:

AUTHORIZATION FOR USE AND DISCLOSURE OF INFORMATION FROM COVINGTON COUNTY HOSPITAL AND CLINICS TO ANOTHER HEALTHCARE ENTITY OR PROVIDER
Patient Information
Patient's Full Name*

First NameMiddle NameLast Name
Patient's Address*

Street Address

Street Address Line 2

CityState

Zip Code
Patient's Date of Birth*

MonthDayYear
Patient's Phone Number*
Please enter a valid phone number.
Fax Number for Record Delivery*
Please enter a valid phone number.
Name/Facility*
Attention*
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number*
Please enter a valid phone number.
Information to be Released
Release
Additional Information
Pursuant to HIPAA 45 CFR, 164.524, we reserve the right to charge a reasonable cost-based fee for producing and mailing the copies. If you want the entire medical record, the rate will increase proportionally based on the cost. At no time will the cost-based fees exceed Mississippi State Law Statute 11-1-51.
Authorization to Release Protected Health Information
I acknowledge and hereby consent to such, that the released information may contain alcohol, drug abuse, psychiatric, behavioral or mental health services, sexually transmitted diseases, HIV testing, HIV results, or AIDS information.*
Initial here
I understand that: I may refuse to sign this authorization and that it is strictly voluntary. My treatment, payment, enrollment, or eligibility for benefits may not be conditioned on signing this authorization. I may revoke this authorization at any time in writing, but if I do, it will not have any effect on any actions taken prior to receiving the revocation.

If I do not specify expiration, this authorization will expire in 90 days. If the requester or receiver is not a healthcare provider, the released information may no longer be protected by Federal Privacy Regulations and may be disclosed. I understand that I may see and obtain a copy of the information described on this form, for a reasonable copy fee, if I ask for it. I can request a copy of this form after I sign and date it.

Please confirm that you have filled out this form in its entirety - if the form is incomplete or invalid, we may be unable to fulfill this request.
Signature*
Date

MonthDayYear
Name of Person Signing Request*

First NameLast Name
Relationship to Patient
Should be Empty:

Authorization to Disclose Protected Health Information

Patient Information

Information to be Released

Authorization to Release Protected Health Information