Med Record Release Authorization Form July 5, 2013 (00286087

AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION FROM MEDICAL RECORD
PATIENT INFORMATION
This authorization is for the release of medical information.
PATIENT'S NAME __________________________________________________________________________________________
Last
First
M.I.
ADDRESS _________________________________________________________________________________________________
BIRTH DATE _________/__________/__________
Month
Day
DAYTIME TELEPHONE NUMBER ___________________________
Year
SOCIAL SECURITY NO. _______________________________
ORGANIZATION PROVIDING INFORMATION:
_________________________________________
ORGANIZATION REQUESTING INFORMATION:
________________________________________
Name of person or organization releasing information
Name of person or organization requesting information
_______________________________________________
Address
_______________________________________________
Address
_______________________________________________
Phone and/or Fax Number
_______________________________________________
Phone and/or Fax Number
INFORMATION TO BE DISCLOSED:
Medical Notes/Summary
PAP/HPV type
Recent Lab
Operative/Procedure Reports____________________
Mammograms/Sonograms (report only, no films)
All Medical Records – limited to 2 years
Pathology__________________________
Pelvic Sono
Mammogram report, film & CD
Bone Density
CXR / EKG
Other: _____________________
(Orange Park office only)
SPECIAL AUTHORIZATION TO DISCLOSE SUPER-CONFIDENTIAL INFORMATION:
ALCOHOL/DRUG/INFECTIOUS DISEASE/MENTAL HEALTH RECORDS are protected by Federal Regulation 42 CFR, Part
2. Release of such records requires specific consent. I hereby grant such specific consent as initialed below. I UNDERSTAND that
these records are protected under federal and state law and cannot be disclosed without my written consent unless otherwise provided
by law. I further understand that the specific type of information to be disclosed may, if applicable, include diagnosis, prognosis, and
treatment for physical and/or mental illness including treatment of alcohol or substance abuse, sexually transmitted diseases, acquired
immune deficiency syndrome (AIDS), or human immunodeficiency virus (HIV) infection.
AS PART OF THE MEDICAL RECORDS CHECKED ABOVE, THE FOLLOWING INFORMATION WILL BE
RELEASED UNLESS STRICKEN:
HIV/AIDS related information and/or records
Sexually transmitted diseases
Mental Health information and/or records
Drug/alcohol diagnosis, treatment or referral information
SIGNATURE: ______________________________________ DATE: _________________________________
Patient or legal representative
1 of 2 pages
09/01/2013
AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION FROM MEDICAL RECORD
PURPOSE OF DISCLOSURE:
Continuing medical treatment
Residence Relocation
Second Opinion
Patient Request
For purposes other than Treatment, Payment and Operations:
(Patient is to receive a copy of the Authorization)
Research
Disability Insurance
FMLA
Life Insurance
Marketing Promotion: I have been informed North Florida OB GYN __is __ is not receiving any direct or indirect
compensation from a third party as a result of disclosing information for this purpose.
Sale of PHI: I have been informed that North Florida OB GYN __is __ is not receiving any direct or indirect
compensation from a third party as a result of disclosing information for this purpose.
Other (please specify): ______________________________________________________________________________
I understand that this authorization will expire one year from the date of signature below.
RIGHT TO REVOKE AUTHORIZATION:
I MAY REVOKE THIS AUTHORIZATION AT ANY TIME, IN WRITING, BEFORE THE INFORMATION HAS BEEN
RELEASED. I FURTHER UNDERSTAND THAT I HAVE A RIGHT TO RECEIVE A COPY OF THIS AUTHORIZATION UPON
REQUEST. I HEREBY RELEASE NORTH FLORIDA OB GYN, LLC FROM ANY AND ALL LEGAL LIABILITY THAT
MAY ARISE FROM THE RELEASE OF THIS INFORMATION TO THE PARTY NAMED ABOVE.
AUTHORIZATION & SIGNATURE:
I hereby authorize the use of disclosure of my individually identifiable health information as described below. I understand that this
authorization is voluntary. I understand that treatment, payment, enrollment or eligibility of benefits may not be conditioned on my
signing this authorization. I further understand that if the organization authorized to receive the information is not a health plan or
health care provider, the released information could potentially be re-disclosed and may no longer be protected by federal privacy
regulations. Therefore, I release WPJ Division of North Florida OB/GYN, LLC from all liability arising from this disclosure of my
health information.
I understand and agree that I am financially responsible for the following fees associated with my request: copying charges and
postage related to the production of my information. For patients and governmental entities: 1.00 per page for the first 25 pages
and 25¢ per page for each page in excess of the first 25 pages. For other entities: up to $1.00 per page for each page copied, in
accordance with Florida Administrative Code 64B8-10.003.
BY SIGNING THIS AGREEMENT, I ACKNOWLEDGE THAT I HAVE CAREFULLY READ,
UNDERSTAND AND AGREE TO THE ABOVE TERMS AND CONDITIONS.
Printed Name of Patient: __________________________________________
Patient Signature: _____________________________________________
Date: ___________________________
Social Security #:______________________
Printed Name of Parent, Guardian or Legal Representative:____________________________________________
Parent, Guardian or Legal Representative Signature:________________ -_____________________________
Relationship to Patient:____________________________________ Records are needed by:_______________(date)
Send by: Fax________ (Patient must initial approval) Mail
2 of 2 pages
Patient will pick up Electronic format if EMR
09/01/2013