Ilanka Community Health Center
705 Second Street – PO Box 2290
Cordova, AK 99574
Ph: 907-424-3622 Fax: 907-424-3275
AUTHORIZATION TO RELEASE PROTECTED HEALTH INFORMATION
I hereby authorize , it’s authorized employees or agents, to
(Entity releasing information)
release information from my health record and speak with relevant persons concerning this information.
Send records to (Name, Address, Fax Number): ________________________________________________________
_______________________________________________________________________________________________
Record Information from these dates of service: From: ________________________To: _______________________
Specific Information to be released: □ Discharge Summary □ History and Physical
□ X-Ray Report(s) □ Pathology Report(s) □ Laboratory Report(s)
□ Consult Report(s) □ EKG □ Other (Specify):_____________________
Sensitive records may require specific patient authorization.
Please initial to authorize the release of the following records.
_________ALCOHOL or DRUG ABUSE RECORDS.
I DO
release the disclosure of any information relating to the diagnosis or treatment of ALCOHOL or DRUG ABUSE. If I authorize the
release of this information, I understand that such information cannot be re-disclosed by a recipient without my specific consent.
_________MENTAL HEALTH RECORDS.
I DO
authorize the disclosure of any information relating to the diagnosis or treatment of MENTAL HEALTH. Indicate if you want to review
the Mental Health records before released.
__________ I DO want to review the MENTAL HEALTH record before it is released
__________ I DO NOT want to review the MENTAL HEALTH record before it is released.
_________ HIV RECORDS.
I DO
authorize disclosure of information which refers to HIV test results, infection status or treatment.
This disclosure is for the purpose of: _______________________________________________________________
I understand that:
• I can refuse to disclose some or all of the information in my treatment records, but refusal may result in an improper diagnosis or
treatment, denial of coverage for a claim for health benefits or other insurance or other adverse consequences. I understand I will not
be denied treatment for refusing to disclose information.
• I can revoke all or part of this authorization at any time during this time period by written notice to Ilanka Community Center, except
where information has already been acted upon for the release of my protected health information.
• I can cross out any provision on this form with which I disagree.
• If information is disclosed to a third party, the information may no longer be protected by the federal or state privacy laws and may
be re-disclosed by the person or entity that receives this information.
• This release may not include records generated at other facilities unless expressly requested above.
• I understand I am entitled to a copy of this authorization, upon request.
This authorization is effective for one year from the date of signing. I authorize
future disclosures to the same individual and/or entities during this time period.
_______________________________ ______________________________
Signature of Patient Date
_______________________________ ______________________________
Signature of Legally Authorized Representative Relationship and Date
_______________________________ ______________________________
Printed Name of Authorized Representative Witness
Patient Name
Date of Birth
Contact Phone
# Pgs. _____Date: _____________
Method:
□ In Person □ ID verified
□ Mail □ Fax
Staff Initials _____________
3.12.20 Y:\1 Ilanka-General\Front Desk
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