AUTHORIZATION TO RELEASE HEALTH CARE INFORMATION

AUTHORIZATION TO RELEASE HEALTH CARE INFORMATION
Name

First NameLast Name
Previous Name/Alias:

First NameLast Name
Date of Birth*

MonthDayYear
Date
Social Security Number*
I request and authorize:*
Provider/Name of Clinic
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Fax #*
Please enter a valid phone number.Format: (000) 000-0000.
to release health care information to: *
Fax #*
Last two office visitsLast active year of treatment/office recordsComplete medical recordsRadiology/Diagnostic Scans (Reports Only)PAP/Mammograms (Reports Only)Most recent ER/Hospital RecordsLab Reports (most recent)Colonoscopy/Pathology/Follow-up PlanOther
Transfer of CareContinuing careAt my (patient) requestWorkers CompensationInsuranceSecond OpinionOther
* I understand that I may revoke this authorization at any time by sending a written notification to the Heartland Health Center. This revocation applies to information that has not already been released.

* I understand that once the requested information is disclosed, it may be re-disclosed by the recipient and the information may not be protected by federal privacy laws.

* I am voluntarily requesting the disclosure of the above health records. I do not need to sign this form to ensure health care treatment.

* Authorization must be signed by the patient or legal guardian of the patient or other authorized representative. If the patient is unable to sign, state reason.

* I understand that all records of treatment for psychiatric/mental health, chemical dependency, STIs and HIV/ AIDS – related illnesses or testing will be released for the dates or conditions given above unless indicated here:
Parent/Patient Signature:*

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SelfParent/GuardianSpouseLegal RepresentativeOther
Date

MonthDayYear
Date
Should be Empty: