MR9120459 (06/14)
MRN: _________________________
CONE HEALTH MEDICAL GROUP
REQUEST & AUTHORIZATION FOR USE/DISCLOSURE OF PROTECTED HEALTH INFORMATION
Please address revocations or inquiries pertinent to this request to (site name, address, phone, and fax):
PLEASE PRINT
Patient Name: ____________________________________ Date of Birth: _____________________________ Phone: ________________________
Address: __________________________________________________________________________________________________________________
City: _____________________________________________________________ State: _________________ ZIP: __________________________
READ THE FOLLOWING CAREFULLY:
Cone Health, its employees, officers, and physicians are hereby released from any legal responsibility or liability for the disclosure of the information listed
below to the extent indicated and authorized herein. I hereby authorize the use or disclosure of my individually identifiable health information as described
below. This includes information pertinent to mental health, drug/alcohol abuse, and HIV/AIDS diagnosis. I understand that this authorization is voluntary. I
understand that, if the organization authorized to receive the information is not a health plan or health care provider, the released information may no longer be
protected by federal or state privacy regulations. I understand that, if I request my records to be e-mailed or faxed, this is not considered secure and my health
information could be viewed by someone other than me.
I understand that unless revoked earlier, this authorization will expire on (DATE):________________________. If no date is indicated, this release will expire 90
days from the date of signature. I understand that I may revoke this authorization at any time by notifying Cone Health in writing; if I do revoke it will not have any
effect on any actions Cone Health took before the revocation was received. I understand that Cone Health cannot make me sign this authorization as a condition
to receive treatment from Cone Health except (i) when Cone Health provides me with research-related treatment, or (ii) when Cone Health provides me with health
care solely for the purpose of creating protected health information for disclosure to someone else.
***THERE MAY BE A CHARGE FOR THE REPRODUCTION OF MEDICAL RECORDS / FILMS / TAPES.***
The reproduction of my Protected Health Information should be provided in the following manner (check all that applies):
Print on paper CD/DVD/USB Mail Fax to #_____________________ Pick up by the authorized recipient
I authorize Cone Health or _______________________________________________________________________ to disclose the following information to:
Name: ______________________________________________________ Phone: ________________________________________________________
Address: ____________________________________________________ City: _________________________ State:_____________ ZIP:___________
The information is to be disclosed for the purpose of:
Continuity of Care Legal Representation School Credit Patient Request
Other (specify) ___________________________________________________________________________________________________________ .
Information to be disclosed:
Dates covering the period(s) of health care from: _____________________________________ to___________________________________________.
Select from the following (check all that apply):
Dates of Service(s) Hospital Discharge Summary History & Physical
Office Progress Notes Lab Test X-ray Reports Other (specify): _____________________________________________________ .
_____________________________________________________________________________________ _____________________________________
Signature of Patient Date
_____________________________________________________________________________________ _____________________________________
Signature of:
Parent Guardian Authorized Representative (attach copy of legal documents) Date
*YOU MAY REFUSE TO SIGN THIS AUTHORIZATION*
OFFICE USE ONLY:
_________________________ ______________________________________________________________ ______________________________
Driver’s License # Staff Signature
(STAFF MUST CHECK LEGAL PICTURE I.D. PRIOR TO SIGNING) Date
DATE PROCESSED: ____________________ NUMBER OF PAGES: ________ INITIALS: _________ CHECK ONE: MAILED FAXED PICKED UP
