premierlungandsleep.com - Authorization for Release of Health Information

Authorization for Release of Health Information
Patient Name:
Date of Birth:

MonthDayYear
Date
Phone Number:
Please enter a valid phone number.
Address:
Section 1: Release Authorization
I hereby authorize Premier Lung & Sleep Institute to:

Release health informationObtain health informationBoth Release & Obtain
To/From (Name/Organization):
Address:
Phone Number:
Please enter a valid phone number.
Fax:
Section 2: Information to Be Released/Obtained

Complete Medical RecordSleep Study Reports (Polysomnography, Home Sleep Test)Office Visit Notes/ER Visits/HPI/Consultations/Discharge Summaries/Hospital VisitsPulmonary Tests/ ReportsImaging/ Radiology Reports (X-ray, CT, MRI, etc.)Lab/ Pathology ResultsOther (specify):
Section 3: Purpose of Disclosure

Continuity of CareInsurance/PaymentLegalPersonal UseOther
Section 4: Expiration & Revocation
- This authorization will expire 12 months from the date signed unless otherwise specified: Type a label .
- I understand I may revoke this authorization in writing at any time, except to the extent that action has already been taken.
Section 5: Patient Rights & Acknowledgment

This authorization is for one year after I, or my personal representative, signs this form. I have the right to revoke this authorization in writing at any time to the Privacy Officer, except to the extent that action has been taken in reliance upon it. I understand that when this information is used or disclosed pursuant to this authorization, it may be subject to re-disclosure by the recipient and may no longer be protected. I hereby release and hold harmless the above named facility and its parent company from all liability and damaged resulting from the lawful release of my protected health information.
Section 6: Signatures
Patient / Legal Representative Name:
Relationship (if not patient):
Signature:

Clear
Date:

MonthDayYear
Date
Witness (if required):
Date:

MonthDayYear
Date
Should be Empty:

Authorization for Release of Health Information

Section 1: Release Authorization

Section 6: Signatures