Patient Name:________________________________Medical Record Number _______________________ Date of Birth:____________________ 1. I authorize the use or disclosure of the above named individual's health information as described below. 2. The following individual or organization is authorized to make the disclosure: ___________________________________________________________________________________ Address_______________________________________________________________________________ 3. The type and amount of information to be used or disclosed is as follows: (include dates where appropriate) Problem list Medication list List of allergies Immunization record Most recent history and physical Most recent discharge summary Laboratory results from (date) _______________to (date)________________ Pathology Slides, accession #________, number sent ______, date sent ______________ X-ray and imaging reports from (date) _______________to (date)________________ X-ray films (radiographs) packaged by ________________________originals copies Consultation reports from (doctors' names)________________________________________ Operative Report from (date)_______________to (date)________________ Admission, Progress Notes from (date)_______________to (date)________________ Entire record Other_________________________________________________________________________________ ______________________________________________________________________________________ 4. I understand that the information in my health record may include information relating to: Sexually transmitted disease Acquired immunodeficiency syndrome (AIDS) or human immunodeficiency virus (HIV) Behavioral or mental health services Diagnosis of or Treatment for alcohol and/or drug abuse Genetic testing 5. This information may be disclosed to and used by the following individual or organization: _______________________________________________________________________________ Address: ______________________________________________________________________________________ For the purpose of________________________________________________________________________ ______________________________________________________________________________________. 6. 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. Unless otherwise revoked, this authorization will expire on the following date, event, or condition: ________________________________________________. If I fail to specify an expiration date, event or condition, this authorization will expire in six months. 7. I understand that authorizing the disclosure of this health information is voluntary. I can refuse to sign this authorization. I need not sign this form in order to assure treatment. I understand that I may inspect or copy the information to be used or disclosed, as provided in CFR 164.524. I understand that any disclosure of information carries with it the potential for an unauthorized redisclosure and the information may not be protected by federal confidentiality rules. I have received a copy of the MTHCS Notice of Information (Privacy) Practices. If I have questions about disclosure of my health information, I can contact the Chief Privacy Officer. _________________________________ ___________________________ Signature of Patient or Legal Representative Date ___________________________________________ ___________________________ If Signed by Legal Representative, Relationship to Patient Signature of Witness Sent via: US Mail FEDEX Other Pick-up (Note: Verify identification, i.e. driver's license)
Form # 2024 Revised 3-2003