Authorization to Release Medical Records

Authorization to Release Medical Records

Muskingum Valley Health Centers (MVHC)
Patient Information
Name

First NameMiddle NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth

MonthDayYear
Date
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Can we leave a message at this number?
Reason for Request
Please select all that apply.
Information to be disclosed by:
If other, please specify here.
Dates of service to be released:

If left blank, two years will be provided.
Date/Year of Service(s) From:

MonthDayYear
To:

MonthDayYear
Records to be released
Check all that apply.
If Other, please describe below:
Delivery Method
If pick-up was selected, please indicate which location.
If email was selected, please enter email below.
Release To: (Name of person/organization/clinic)
Address

Street Address

Street Address Line 2

CityState

Zip Code
Phone
Please enter a valid phone number.Format: (000) 000-0000.
Fax
Please enter a valid fax number.Format: (000) 000-0000.
PROHIBITION ON REDISCLOSURE:
I understand this information has been disclosed from records whose confidentiality is protected by Federal law. Federal regulations (42 CFR part 2) may prohibit you from making any further disclosure of this information except with the specific written consent of the person to whom it pertains. A general authorization for the release of medical or other information, if held by another party, is not sufficient for this purpose. Federal Regulations state that any person who violates any provision of this law shall be subject to prosecution under Federal law.
AUTHORIZATION AND EXPIRATION:
+ I understand that if the person or entity that receives the above information is not a health care provider or health plan covered by federal privacy regulations, the information described above may be redisclosed by such person or entity and will likely no longer be protected by the privacy regulations.

+ Muskingum Valley Health Centers will not condition treatment, payment, enrollment or eligibility for benefits on whether you sign the authorization when the prohibition on condition of authorizations applies.

+ I understand that my records/protected health information cannot be released unless I sign this form.

+ I understand that this authorization may include information concerning testing, diagnosis or treatment of HIV (Human Immunodeficiency Virus), AIDS (Acquired Immunodeficiency Syndrome), PSYCHIATRIC and/or DRUG/ALCOHOL TREATMENT and/or ASSAULT RECORDS that may be in my medical record.

+ As described in the Notice of Privacy Practices of Muskingum Valley Health Centers, I understand that I may revoke this authorization in writing at any time, except to the extent that action has been taken by Muskingum Valley Health Centers in reliance on this authorization, by sending a written revocation to the entity’s Medical Records Department.
Signature of Patient:
Typed Full Name of Patient
Signature of Representative/Guardian of Patient:
Typed Name of Representative/Guardian
Relationship to Patient:
Today's Date

MonthDayYear
Date
Should be Empty:

Authorization to Release Medical Records

Patient Information

Reason for Request

Dates of service to be released:

Records to be released

PROHIBITION ON REDISCLOSURE:

AUTHORIZATION AND EXPIRATION: