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Medical Records

Fax Form


Authorization to Use or Disclose Health Information

Patient Name: _______________________________________________

Phone #:  _______________________

Date of Birth:  ____________________

SS #:  ________________________________

Medical Record Number:  ____________________________

1. I authorize the use or disclosure of the above named individual's health information as described below
2. The following individual(s) or organization(s) are authorized to make the disclosure:

_________________________________________________________________________________
  

  3. The type of information to be used or disclosed is as follows: (check the appropriate boxes and include other information where indicated)
Date(s) of Service: 

____________________________________________________________________

__ Face Sheet / Registration Sheet / Referral Sheet 
__ Discharge Summary
__ ER Record
__ H&P
__ Consults
__ Progress Notes
__ Discharge Instructions
__ Lab Results
__ Radiology Results
__ EKG / Cardiology Testing Results 

__ Operative Report
__ Implant Information
__ Pathology Report
__ Medication List
__ Behavioral Health Information
__ Substance Abuse Information
__ Human Immunodeficiency Virus (HIV) Information
__ Entire Record
__ Home Care Records
__ OTHER: please specify ______________  


 4. I understand that if my authorization includes Behavioral Health, substance abuse or HIV information, it may include; (i) information concerning whether an individual has been the subject of an human immunodeficiency virus (HIV) - related test, has HIV, an HIV related illness, acquired  immunodeficiency syndrome (AIDS), and/or including information pertaining to the individual's contact (Section 7100.133); (ii) substance abuse information in my health record may include whether or not I am receiving treatment, my prognosis, a brief description of my progress, and/or a short statement as to whether I have relapsed into substance abuse and the frequency of such relapse (Pennsylvania Drug and alcohol abuse control act of 1972 - act 148 section 7(e); (iii) behavioral health information services. (Mental Health Procedures act 1976, section 5100.3-39).
 

5. The information identified above may be used by or disclosed to the following individual or organization(s):

Name: _______________________________________________________________ 

Address:  _____________________________________________________________

6. This information for which I'm authorizing disclosure will be used for the following purpose:
  __ Sharing with other health care providers as needed    __ Other (please describe): 

        _________________________________________________________________
   

7. I understand that I have a right to revoke this authorization at any time. I understand that if I revoke this authorization, I must do so in writing and present my written revocation to the medical record department. I understand that the revocation will not apply to information that has already been released in response to this authorization. I understand that the revocation will not apply to my insurance company when the law provides my insurer with the right to contest a claim under my policy.

8. Unless I specify differently, this authorization will expire six months from the date signed below:

9. I understand that once the above information is disclosed, it may be redisclosed by the recipient and the information may not be protected by federal privacy laws or regulations.

10. I understand authorizing the use or disclosure of the information identified above is voluntary. I need not sign this form to ensure healthcare treatment.

 

______________________________________________
Signature of patient or legal representative            

 

_______________
Date

If signed by legal representative, relationship to patient   ________________________
________________________________________
Signature of witness
_____________  
Date
I have been offered a copy of this Authorization Form
    __ Accept     __ Refuse

The patient has given verbal authorization to release the above identified information. I have witnessed the verbal authorization.  The patient has been informed of the nature of the authorization and freely gives his or her consent.

_______________________________________
Signature of witness 
_________
Date
_______________________________________
Signature of witness 
_________
Date


FORM# 020906  REV 7/03

Fax  this form to Health Information Management at  215-710-5822
For additional information, please contact our Correspondence Coordinator at 215-710-2084