AUTHORIZATION TO DISCLOSE PROTECTED HEALTH INFORMATION
Only One Patient and Facility Per Form
Today's Date:
*
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Month
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Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Patient Name:
*
Email
example@example.com
Date of Birth:
*
/
Month
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Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Phone Number:
*
SSN:
*
I hereby request and authorize you to release information TO or FROM:
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To another individual or organization from GMA
From another individual or organization to GMA
Individual or Organization Name
*
Address of Individual or Organization
*
Disclosure Method
Pickup at GMA
Mail
Fax
Fax number if selected above
I authorize the use or disclosure of the above named individual's heath information as described below. Information to be released:
All Records of Treatment from
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Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
to
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Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
*
Entire (Complete Record)
Medication Record
Allergy List
Physician’s Orders
X-ray Reports
History & Physical Report
Consultation Report
Progress Notes
Drug/Alcohol Information
Operative Report
Lab Results
Psychiatry Records
Immunization Results
HIV Results
Operative Report
Other
Financial Information to Specific Individual
I understand that the information
in my health record may include information relating to sexually transmitted disease, behavio
ral or
mental health services, and treatme
nt for alcohol and drug abuse.
I understand there will be a charge for copying records th
at will be paid prior to receiving my health record.
I understand that the above-listed item or information in Clinic's possession may have been generated by Clinic or by any other
source
and may be released to the above-listed Clinic.
I understand that if the person or entity th
at receives the information is
not a healthcare provider or a health plan covered by federal pri-
vacy regulations the information described above may be re-disclosed and no longer protected by these regulations.
I understand that authorizing the disclosure of this health information is voluntary. I can refuse to sign this authorization.
I understand
that I may inspect or copy the information to be used or disclosed, as provided in the federal privacy regulations. If I have q
uestions, I can
contact Clinic's Privacy/Security Officer.
Unless otherwise revoked, this authorization will expire on the following date, event or condition.
Please specify date, event or condition (you may write max or maximum)
I understand that I may revoke this authorization in writing at any time by contacting the Clinic's Privacy Officer.
I understand that this revocation does not apply to information that has already been released in response to this authorization.
I certify that I have recied a signed copy of this authorization.
Signature of Patient or Legal Guardian
*
Relationship to Patient of other than Self
Today's Date
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
I revoke (cancel) this Authorization to Disclose Health Information previously signed on
Previous Date if revoking
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Cancellation Signature if revoking:
Today's Date if revoking:
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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