DO NOT WRITE IN THIS AREA
ROI (09/2013) 1.1
DO NOT WRITE IN THIS AREA
AUTHORIZATION FOR USE AND/OR
DISCLOSURE OF PROTECTED
HEALTH INFORMATION
Patient Identication
Printed Name: _______________________________________________________________________ Date of Birth: _____________________
Address: ___________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
Social Security #: __________________________________________ Telephone: _________________________________________________
Information To Be Released – Covering the Periods of Health Care
From (date) ______________________________________________ to (date) ___________________________________________________
Please check type of information to be released:
Other, (specify) ____________________________________________________________________________________________________
Purpose of Request
Treatment or consultation At the request of the patient Billing or claims payment
Other, (specify) ____________________________________________________________________________________________________
Person Authorized to Receive Information
Name: _______________________________________________________________________________________________________________
Address: _____________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
Drug and/or Alcohol Abuse and/or Psychiatric, and/or HIV/AIDS Records Release
I understand that if my medical or billing record contains information in reference to drug and/or alcohol abuse, psychiatric care, sexually
transmitted disease, Hepatitis B or C testing, and/or other sensitive information, I agree to its release. Check One: Yes No _____ Initials
I understand that if my medical or billing record contains information in reference to HIV/AIDS (Human Immunodeciency Virus/Acquired
Immunodeciency Syndrome) testing and/or treatment, I agree to its release. Check One: Yes No _____ Initials
Time Limit and Right to Revoke Authorization
Except to the extent that action has already been taken in reliance on this authorization, at any time I can revoke this authorization by
submitting a notice in writing to the facility Privacy Officer at 250 Old Hook Road, Westwood, NJ 07675. Unless revoked, this authorization will
expire on the following date or event____________________________________________________________________________________.
Re-disclosure
I understand the information disclosed by this authorization may be subject to re-disclosure by the recipient and will no longer be protected by
the Health Insurance Portability and Accountability Act of 1996. 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 Personal Representative Who May Request Disclosure
I understand that Hackensack UMC at PV may not condition my treatment on whether I sign this authorization form unless specified above under
Purposes of Request. I can inspect or copy the protected health information to be used or disclosed.
I authorize Hackensack UMC at PV to use and disclose the protected health information specified above.
Signature: __________________________________________________________________________ Date: ___________________________
Authority to Sign if not patient: __________________________________________________________________________________________
Identity of Requestor Veried via: Photo ID Matching Signature Other, specify ____________________________________________
Veried by: _______________________________________________________
□ Entire Medical Record
□
History and physical exam
□
Laboratory test results/reports
□
Operative report
□ Pathology report
□ Consultation reports
□ X-ray reports
□ Emergency room record
□ Discharge summary
□ Progress notes
□ X-ray films/images
□ Itemized bill
□ The following marketing purposes: _________________________________________________________________________
This marketing activity involves direct or indirect compensation/payment from a third party to Hackensack UMC at PV for this use
of protected health information. Check One: □ Yes □ No _____ Initials
Payments to Facility
HEALTH INFORMATION
FAX: (201) 781-1111
