Authorization to release Genetic Medical Information

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Authorization to Release Genetic Medical Information

Department of Medical Genetics and Genomic Medicine

Telephone (732) 745-6659

Fax Number (732) 249-2687
Genetic Medical Records are protected under the New Jersey Genetic Privacy Act (P.L. 1996, c.126 (C. 10:5-43 et al.) In completing this authorization to release genetic medical information form, I understand this may include information regarding family history, medical history, physical examination, laboratory results, genetic test results, and/or diagnosis and prognosis and that this information may be in the form of verbal communication and/or hard copy documentation.

PATIENT INFORMATION
Patient Name *

First NameLast Name
Patient's date of birth*

MonthDayYear
Date
Is the Patient a minor or has an Authorized Legal Representative?*

YesNo
Authorized Legal Representative's Full Name

First NameLast Name
Description of Authority
Please select one*

Please DO NOT release any medical information. By selecting this, I understand that failure to forward our consultation may result in compromised medical care due to insufficient information and/or guidance.Please release medical information to the providers listed below. By selecting this, I understand that I am responsible for the accuracy of the Physician's name/practice/address/phone and fax numbers.
1) Name of Provider or their Practice*
1a) Address of Provider's Practice*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
1b) Phone Number of Practice*

Area CodePhone Number
1c) Fax Number of Practice*

Area CodePhone Number
Do you have additional physicians?*

YesNo
2a) Physician name or practice
Please specify if this is your primary care provider or a specialist.
2b) Practice Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
2c) Practice Phone Number

Area CodePhone Number
2d) Practice Fax

Area CodePhone Number
3a) Physician name or practice
Please specify if this is a primary care provider or specialist.
3b) Practice Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
3c) Practice Phone Number

Area CodePhone Number
3d) Practice Fax

Area CodePhone Number

PURPOSE OF RELEASE
I authorize the Department of Medical Genetics and Genomic Medicine at Saint Peter's University Hospital to release my health information for purposes of continuity of care and ongoing medical management with my specified health specialists.

TERM/EXPIRATION
This Authorization is valid for a period of one year ("Term")

SIGNATURE
I accept that information given to me based on this request will not include information compiled in anticipation of (or for use in) a civil, criminal or administrative proceeding or as may otherwise be prohibited by law.
I accept that Saint Peter's University Hospital may deny this request on a limited basis under federal and state law protecting the privacy of health information. I further accept that, except as otherwise prohibited under applicable law, I have the right to have a denial of my request reviewed by a licensed health care practitioner selected by Saint Peter's University Hospital who did not take part in Saint Peter's University Hospital’s finding to deny my request.
I accept that Saint Peter's University Hospital will notify me of its finding to approve or deny my request to access or obtain a copy of the requested information within thirty (30) days of getting this request.
The information to be disclosed from my records is confidential and is protected by federal and state law. I accept that once Saint Peter's University Hospital releases my health information to the person(s) listed on this Authorization, Saint Peter's University Hospital cannot guarantee that the person(s) will not re-disclose my health information to a third party. The third party may not be required to abide by this Authorization or applicable federal and state law governing the use and disclosure of my health information.
I accept that this Authorization will stay in effect until its Term expires, or I provide a written repeal to Saint Peter's University Hospital. The repeal will be effective immediately upon Saint Peter's University Hospital’s receipt of my written notice, except that the repeal will not have any effect on any action taken by Saint Peter's University Hospital in good faith before Saint Peter's University Hospital received my written notice of repeal.
I have read, understand and accept the terms described in this Authorization and I have had the opportunity to ask questions about my rights to access my health information and any Protected Health Information that Saint Peter's University Hospital uses to make medical decision about me. I also understand that if I have further questions or concerns about my Protected Health Information, I may contact Saint Peter's University Hospital Department of Medical Genetics and Genomic Medicine by mail: 254 Easton Avenue, New Brunswick, New Jersey 08901 or by telephone at (732) 745-6659 or by fax (732) 249-2687.
I have read the above and hereby request and authorize the Department of Medical Genetics and Genomic Medicine at Saint Peter's University Hospital to release/disclose the health information as listed for the purposes as written in this Authorization.*

YesNo
Patient Signature*

Clear
Date

MonthDayYear
DateHourMinutesAM/PM Option
Legal Authorized Representative Signature:

Clear
Date

MonthDayYear
DateHourMinutesAM/PM Option
Interpreter/Translator Name

First NameLast Name
Interpreter/Translator

Clear
Date

MonthDayYear
DateHourMinutesAM/PM Option
Email for confirmation of receipt
example@example.com
Should be Empty: