Explanation of Form
Laws and regulations require that some sources of personal information have a signed authorization or permission form before releasing it. Also, some laws require specific authorization for the release of information about certain conditions and from educational sources.
“Of What”: Entire Medical Record would include all records and other information regarding my health history, treatment, hospitalization, tests, and outpatient care. This information may relate to sensitive health conditions.
“To Whom”: I understand that for those listed in the TO WHOM section who are healthcare providers, my permission would also include physicians, other health care providers (such as nurses) and medical staff who are involved in my medical care at that organization’s facility or that person’s office, and health care providers who are covering or on call for the specified person or organization, and staff members or agents (such as business associates or qualified services organizations) who carry out activities and purposes permitted by this form for that organization or person that I specified. Disclosure may be of health information in paper or oral form or may be through electronic interchange.
“Purpose”: Note: Your signature on this form does NOT allow health insurers to have access to your health information for the purpose of deciding to give you health insurance or pay your bills. You can make that choice in a separate form that health insurers use.
“Withdrawal”: You have the right to revoke this authorization and withdraw your permission at any time, except to the extent a source of information is relied on it to take an action. Note: Organizations that access your health information while your permission is in effect may copy or include your information in their own records. Even if you later decide to withdraw your permission, they are not necessarily required to return it or remove it from their records.
“Re-disclosure of Information”: Any health information about you may be re-disclosed to others only to the extent permitted by state and federal laws and regulations. I understand that once my information is disclosed, it may be subject to lawful re-disclosure, in accordance with applicable state and federal law, and in some cases, may no longer be protected by federal privacy law.