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Sample Authorization for Disclosure
of
Health Information
- I hereby authorize
(name of provider) to disclose the following information from
the health records of:
Patient Name:_______________________________ Date of
Birth:_____________________
Address:_________________________________________________
Telephone: ______________________ Patient Number: ____________
Covering the period(s) of healthcare:
From (date) ___________________ to (date)____________________
From (date) ___________________ to (date)____________________
- Information to be disclosed:
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___Complete health record(s) |
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___Discharge Summary
___History and Physical Exam.
___Consultation Reports |
___Progress Notes
___Laboratory Tests
___X-ray Reports |
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___Photographs, videotapes,digital or other
images |
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___Other (please specify)__________________ |
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3.
I understand that this will include information relating to (check if
applicable):
___AIDS (Acquired Immunodeficiency Syndrome) or HIV (Human
Immunodeficiency Virus) infection
___Psychiatric care
___Treatment for alcohol and/or drug abuse
- This information
is to be disclosed to_______________________________for the purpose
of________________________________________.
- I understand this
authorization may be revoked in writing at any time, except to the
extent that action has been taken in reliance on this authorization.
Unless otherwise revoked, this authorization will expire on the
following date, event, or condition:
_____________________________________
- The facility, its employees, officers, and
physicians are hereby released from any legal responsibility or
liability for disclosure of the above information to the extent
indicated and authorized herein.
_________________________________________________________
Signature of Patient or Legal Representative
Date
_________________________________________________________
Signature of Witness
Date
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