Authorization Release of Information

Authorization Release of Information

Authorization for the disclosure of health information - Releasing from LCPH to an individual or other agency
Federal law says that we cannot share your health information without your permission, except in certain situations. If you sign this form, you are giving us permission to share the health information you indicate below. This does not prevent the information from being re-shared by the recipients.

Please complete the following information for the request of release of records from Lewis and Clark Public Health (LCPH). Please allow 4 business days for request to be processed.

You will need to fill out a new request per facility or person.

If you need help with this form, please call 406-457-8900.
Name of Patient:*

First NameMiddle NameLast Name
Other Names Used: (maiden name, previous name, etc.)

First NameLast Name
Patients Date of Birth: *

MonthDayYear
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
The purpose of this records request is (please select one):*

Coordination/Continuity of Care (ex: ongoing appts/visit summaries/updated care plans, etc.)Client RequestOther
I am requesting the following Protected Health Information (PHI) to be released from LCPH (please check all that apply):*

Immunization Records (this includes immunization records recorded in imMTrax)Immunization Lab Results (HepB, Titers, Varicella Titers, etc.)Travel Clinic RecordsTuberculosis Screening/TreatmentCommunicable Disease Diagnosis (Sexually transmitted infection (STI), Salmonella, Pertussis, HIV, etc.)Restriction/Exclusion and Release LettersOther
Select the Date of Services Requested:
All Records Specific Dates: Date* to Date
Further information about the Release (if applicable): Please specify
Please release the selected PHI to:*

SelfHealthcare ProviderOther Clinic/Care CenterMy EmployerOther
Please release the selected Protected Health Information by:*

I will pick up in person at Lewis and Clark Public Health (1930 9th Ave)USPS MailFaxSecured Email
Please provide necessary recipient information below:
Individual/ATTN To:

First NameLast Name
Organization (If applicable):
Mailing Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Fax Number:
Please enter a valid phone number.
Email address to send secured email:
example@example.com
Recipient Information. Please click on "+ Add Row" to add multiple locations:
Please provide a phone number where we can reach you with any questions about this form: *
Please enter a valid phone number.
Please upload a current copy or photo of your government-issued ID Card:*

Ex: Driver's license, Real ID, Identification Card, Passport
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Unless otherwise revoked, this authorization will expire one year after it is signed. By signing this authorization, I acknowledge that:
- Based on my selection above, my record may contain information regarding the screening for HIV (human immunodeficiency virus), other bloodborne pathogens (Hepatitis B, Hepatitis C), or sexually transmitted infections (STI). I give my specific authorization for these records to be released.
- Only records maintained by Lewis and Clark Public Health (LCPH) will be released.
- With this request on file, immunization records from the State Registry imMTrax, also can be released.
- I have the right to revoke this authorization at any time. Revocation must be done in writing. I understand that I cannot revoke an authorization for information that has already been released in response to this authorization.
- This authorization is voluntary. I can refuse to sign this authorization. I need not sign this authorization to receive treatment. Refusing to sign this authorization will not affect payment for services, enrollment, or eligibility for benefits.
- I won't hold Lewis and Clark Public Health responsible for any problems that occur from following this Authorization.
- I may inspect or copy this authorization provided in 45 CFR 164.524. I understand that any disclosure of information under this authorization carries with it the potential for an unauthorized re-disclosure by the recipient and, after it is disclosed, the information may not be protected by state or federal confidentiality rules. If I have questions about disclosure of my health information, I can contact Lewis and Clark Public Health (LCPH) at 406-457-8900.
Client/ *Authorized Representative Signature*

Clear
Date

MonthDayYear
Date
By signing this form, I agree that the information I provided is accurate and truthful, and I agree with the acknowledgement and consent above.

*Parent, Legal Guardian or Legal Representative.

Supporting legal documentation must accompany this form when services are requested by the client's Legal Guardian or Legal Representative.
Printed name of person signing/requestor*

First NameLast Name
Relationship to client:*

SelfParentLegal GuardianPower of AttorneyOther
Please upload proof of relationship, if applicable

Ex: Power of Attorney, Legal Guardian, Legal Representative, etc.
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Please verify that you are human*
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