Pulmonary Medicine Associates | Medical Record Release Form

Authorization For Release of Confidential Health Information
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Phone Number
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Address

Address

Street Address Line 2

City, State, ZipState / Province

Postal / Zip Code
I hereby authorize the protected health information regarding the above-named person to be exchanged to: Person/Institution/Other:
Person/Institution/Other:
Address

Address

Street Address Line 2

City, State, ZipState / Province

Postal / Zip Code
I authorize the release of information pertaining to the following time periods:
From Date(s):

MonthDayYear
Date
To Date(s):

MonthDayYear
Date
The following types of information is to be disclosed are as follows:

History and Physical ExamintionAbstract (documents summarizing history)Consultation ReportsDiagnostic Reports (labs, x-rays, etc.)Progress NotesX-ray FilmsOperative ReportOther
The following highly confidential items must be checked to include in the disclosure:

HIV/AIDS-related health informationBehavioral or mental health information/recordsDrug/alcohol diagnosis, treatment, referral informationGenetic testing information/recordsOther
The purpose of the authorization is:
This authorization expires in 24 months from the date of request.

If not specified, this release will expire 1 year after the date of signature.
- I understand that I have the right to inspect and copy the information I have authorized to be disclosed by this authorization. In the event, I refuse to allow the release of the above-described information. I understand that it will not be disclosed, except as provided by law.
- I understand that the practice may not condition treatment on whether I sign this authorization, except when health care is provided solely to create protected health information for disclosure to a third party.
- I understand that information used or disclosed under this authorization may be subject to disclosure by the recipient and no longer be protected by law.
- I understand that this authorization is valid until it expires unless revoked before that.
- I understand that I may revoke this authorization at any time by giving written notice to the physician of my desire to do so. I also understand that I will not be able to revoke this authorization in cases where the physician has already relied on it to use or disclose my health information. Written revocation must be sent to the physician's office.
- I have read and understood the terms of this authorization and I have had the opportunity to ask questions about the use and disclosure of my health information. By my signature, I knowingly and voluntarily authorize Pulmonary Medicine Associates, SC to use or disclose my health information in the manner described above.
Name*

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Date*

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Date
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Authorization For Release of Confidential Health Information