Form no. 07605 CNDH Medical Records Rev. 7/2017
AUTHORIZATION FOR ACCESS BY PATIENT OR DISCLOSURE OF
PROTECTED HEALTH INFORMATION
Patient’s name: Medical record no:
Date of birth: Last 4 digits of Social Security no:
Phone no.:
I hereby authorize the use or disclosure of the Protected Health Information (PHI) described below to be provided to or obtained by the following (please
provide complete address):
Name of individual/facility/company/job title to receive PHI: Name of individual/facility to disclose PHI:
Address: Address:
City, state, ZIP: City, state, ZIP:
Phone no.: Fax: Phone no.: Fax:
Portions to Release are: □ Health summary □ Face sheet □ History & physical □ Provider’s progress notes
□ Lab □ Discharge summary □ Cardiology □ Operation report □ Provider’s orders
□ Nurse’s notes □ Dental films □ Imaging reports □ Imaging/X-ray CD/DVD
□ Behavioral health counseling □ Behavioral health CONFIDENTIAL or PSYCHIATRIC notes*
□ Other (specify):
* Please note federal law requires additional authorization from your mental health provider prior to release of this content.
Date(s) of visit(s) needed:
The information shall be obtained used or disclosed for the following purpose(s) only:
□ Insurance □ Continued treatment □ Legal □ At the request of the patient or patient’s representative
□ Other (specify):
I understand:
I may revoke this authorization at any time, in writing, except revocation will not apply to information already used or disclosed in response to
this authorization. I may revoke this document by presenting my written revocation as provided in the Notice of Privacy Practices. Unless
revoked or otherwise indicated, the automatic expiration date will be one year from the date of signature or upon occurrence of the following
event:
I release the entities listed above, their agents and employees from any liability in connection with the use or disclosure of the protected health
information covered by this authorization. The entity authorized to disclose the information will not be compensated by the recipient for the
disclosure, except for the cost of copying and mailing as authorized by law.
Information used or disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and no longer protected by federal
law. However, the recipient may be prohibited from disclosing substance abuse information under the Federal Substance Abuse
Confidentiality Requirements.
I have the right to inspect the health information to be released and I may refuse to sign this authorization.
Unless the purpose of this authorization is to determine payment of a claim for benefits, the requesting entity will not condition the provision of
treatment or payment for my care on my signing this authorization.
I understand that copies of my health information are allowed by law; however, I do understand that copies requested for the same day of an
encounter may not be readily available on that same day, but at a later date, due to documentation requirements.
I understand that my medical information may indicate that I have a communicable or non-communicable disease which may include, but is not limited to,
diseases such as hepatitis, syphilis, gonorrhea or the human immunodeficiency virus, also known as Acquired Immune Deficiency Syndrome (AIDS). I further
understand that my medical information may indicate that I have or have been treated for psychological or psychiatric conditions or substance abuse.
ACCIDENT, INJURY OR ON THE JOB INJURY
I authorize the Chickasaw Nation Department of Health to release information contained in its hospital records to the Worker’s Compensation Insurance Carrier concerning
the diagnosis, treatment and prognosis of the undersigned patient. The records may also be used for any matter involved in the workers’ compensation claim, including
proof of hospital bills incurred for the treatment of the patient, filling the same in court and furnishing copies to the involved parties.
_______________________________________________________ ____________________________
Signature of patient or legal representative Date/time
Signature of patient or legal representative Date/time
Description of legal representative’s authority Expiration date of authorization
NOTICE OF RIGHTS: Information in your medical record that you have or may have a communicable or venereal disease is made confidential by law and cannot be
disclosed without your permission except in limited circumstances including disclosure to persons who have had risk exposures, disclosure pursuant to an order of the court or
the U.S. Department of Health, disclosure among health care providers or disclosure for statistical or epidemiological purposes. When such information is disclosed, it cannot
contain information from which you could be identified unless disclosure of that identifying information is authorized by you, by an order of the court or the U.S. Department of
Health or by law.
Bill Anoatubby
Governor
Governor
