Medical Records Release Authorization

Authorization for Release of Church Health Medical Information

Church Health 1350 Concourse Avenue, Suite 142 Memphis, TN 38104 (901)272-0003/(FAX) 901 261-8830
Patient Name

First NameLast Name
Patient Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Patient Social Security Number
Patient Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Patient Telephone #
Format: (000) 000-0000.
I hereby authorize Church Health:
To release information from the medical records of the above-named patient.
Church Health will send/give Records To:
Name of person/organization to which disclosure is to be made
Please choose method of delivery
Address of person/organization to which disclosure is to be made

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Fax # of person/organization to which disclosure is to be made (if needed)
Phone # of person/organization to which disclosure is to be made
Format: (000) 000-0000.
Medical Records include: Physician and/or provider notes, vital sign flow sheet, lab test results, medications prescribed, x-ray and mammography reports.
Note: Records about HIV status and sexually transmitted diseases to be included unless otherwise specified. Counseling or psychotherapy notes require specific, separate request and review by staff before release.
Please specify which records are to be released, including date range
include date range, as well as department such as Medical, Dental, Optometry, Physical Therapy, Counseling, etc. If all Church Health reocrds are needed, type ALL RECORDS
This authorization is valid for one year from date of signature unless it is revoked by written request. It covers only treatment(s) for the dates specified above.
If you'd like this authorization to have a different expiration date, please enter it here

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
I, the undersigned, have read the above and authorize the staff of Church Health to disclose such information as herein contained. I have the right to revoke this authorization in writing at any time except to the extent that action has been taken in reliance upon it. I understand that I do not need to sign this form to get treatment, payment, health plan enrollment nor eligibility. I understand that when this information is used or disclosed pursuant to this authorization, it may be subject to re-disclose by the recipient and may no longer be protected. My health records may be provided via Datavant Health, a third party service. I hereby release and hold harmless Church Health from all liability and damages resulting from the lawful release of my Protected Health Information. I understand I may have a copy of this form if I want it.
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Signature of Patient/ Parent/Conservator/Guardian
Authority/Relationship to patient
Patient fee is $20 for records. Fees/charges will comply with all laws and regulations applicable to release of Protected Health Information. Payment is due at time of release to the patient or time of request if mailed to patient. Records picked up from clinic by anyone other than the patient require individual to have photo identification.
Should be Empty:

Authorization for Release of Church Health Medical Information