Nashville Health Information Management Service Center (HSC)
Release of Information, PO Box 290429, Nashville TN, 37229
Phone: 615.695.8700 Toll Free: 866.270.2311 Fax 855.901.6104 (rev 8/24/15)
Section A: This section must be completed for all Authorizations
Last 4 digits SSN (optional):
Recipient’s Name: Recipient’s Phone:
This authorization will expire ninety days from the date of signature unless otherwise indicated below.
Date: Event:
Request Delivery (If left blank, a paper copy will be provided): Paper Copy Electronic Media, if available (e.g.,USB
drive, CD/DVD) Encrypted Email Unencrypted Email
_________________________________________________________________________________________________
NOTE: In the event the facility is unable to accommodate an electronic delivery as requested, an alternative delivery
method will be provided (e.g., paper copy). There is some level of risk that a third party could see your PHI without your
consent when receiving unencrypted electronic media or email. We are not responsible for unauthorized access to the
PHI contained in this format or any risks (e.g., virus) potentially introduced to your computer/device when receiving PHI
in electronic format or email.
Is this request for psychotherapy notes? Yes, then this is the only item you may request on this authorization. You must submit
another authorization for other items below. No, then you may check as many items below as you need.
Description: check all that
apply
Description: Description:
check all that apply
Description: check all that
apply
All PHI in medical record
Admission form
Dictation reports
Physician orders
Intake/outtake
Clinical Test
Medication Sheets
Operative Information
Cath lab
Special test/therapy
Rhythm Strips
Nursing Information
Transfer forms
ER Information
Labor/delivery sum.
OB nursing assess
Postpartum flow sheet
Itemized bill:
UB-92:
Other:
Other:
I acknowledge, and hereby consent to such, that the released information may contain alcohol, drug abuse, psychiatric, HIV testing, HIV
results or AIDS information. _______________ (Initial) If not applicable, check here.
I understand that:
1. I may refuse to sign this authorization and that it is strictly voluntary.
2. My treatment, payment, enrollment or eligibility for benefits may not be conditioned on signing this authorization.
3. I may revoke this authorization at any time in writing, but if I do, it will not have any affect on any actions taken prior to receiving the
revocation. Further details may be found in the Notice of Privacy Practices.
4. If the requester or receiver is not a health plan or health care provider, the released information may no longer be protected by federal
privacy regulations and may be re-disclosed.
5. I understand that I may see and obtain a copy the information described on this form, for a reasonable copy fee, if I ask for it.
6. I get a copy of this form after I sign it.
Section B: Is the request of PHI for the purpose of marketing?
If yes, the health plan or health care provider must complete Section B, otherwise skip to Section C.
Will the recipient receive financial or in-kind compensation in exchange for using or disclosing this information?
I have read the above and authorize the disclosure of the protected health information as stated.
Signature of Patient/Patient’s Representative:
Print Name of Patient/Representative:
*roi*
