Authorization For Release of Medical Information

Authorization For Release of Medical Information

Authorize St. Anthony Regional Hospital and Nursing Home to release your medical information to a designated recipient.
Patient Name:

First NameLast Name
Patient Date of Birth

MonthDayYear
Date
Record No.
I, the undersigned, do authorize and request provider name to release information to .
Complete Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Check the information to be disclosed (include dates where indicated) Minimum necessary or specify:
For the following dates:
Dates For: Summary of Stay Including Discharge Summary, Discharge Instruction, History and Physical
For the following dates:
Dates For: Clinic Notes
For the following dates:
Dates for: Other, please specify
Purpose of releasing information:
I understand that the records released may contain information related to the following and I authorize its release: (Please initial by all those that apply)
Mental Health
Drug & Alcohol Abuse
AIDS/HIV Related Information
* I understand that the confidentiality of these records will be protected in compliance with state and/or federal law. No information will be released without my written consent unless disclosure is permitted by court order, or to medical personnel in a medical emergency or for research/monitoring programs.
Patient Name

First NameLast Name
I understand that this authorization is voluntary and that I may cancel this consent to release information at any time by sending written notice to: Director of Health Information, St. Anthony Regional Hospital, PO Box 628, Carroll, IA 51401. The cancellation will not be effective until received by the above.

I understand that any release that was made prior to my cancellation in compliance with this authorization, shall not constitute a breach of my rights to confidentiality. Disclosure of this information carries with it the potential for unauthorized re-disclosure and once information is disclosed it may no longer be protected by federal privacy regulations.

I understand that I may review the disclosed information or ask questions by contacting the Director of Health Information Management at the above address.

I understand that St. Anthony may not require completion of this form as a condition of treatment. However, when the provision of services is solely for the purpose of creating a medical report (protected health information) for a third party, refusal to sign may result in denial of those services.

This agreement will expire one year from the date of signature, unless previously revoked or otherwise indicated (specify number of days or months or date)
Specify number of days or months or date
Signature of Patient or Legal Guardian
Date

MonthDayYear
Complete Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Witness Signature
Relationship (if not the patient)
Expiration Date of Authorization

MonthDayYear
By completing this form you will only receive hospital (not clinic) records.

Questions? Health Information Management

Phone: 712-794-5557

Fax: 712-794-5480
Should be Empty: