EAST CENTRAL UNIVERSITY HEATH SERVICES
AUTHORIZATION
FOR
ACCESS
BY
PATIENT
OR
DISCLOSURE
OF
PROTECTED HEALTH INFORMATION
Patient's
Name:-
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Medical
Record#:-
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Date
of
Birth:--
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Social Security#:
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I hereby authorize the use
of
disclosure
of
the Protected Health Information (PHI) described below to
be
provided
to
or
obtained by the following:
Name
of
Individual/Facility/Company to Receive PHI: Name oflndividual/Facility to Disclose PHI:
Address:-
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Address:----
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City, State:
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City,
State:-------
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Portions to Release are: 0 Heath Summary 0 Face Sheet 0 History & Physical 0 Doctor's Progress Notes 0 Lab/X-ray 0 Discharge Summary
0 Path Report 0 EKG!Echo 0 Operation Report 0 Doctor's Orders 0 Nurse's Notes 0 Behavioral Health Records 0 Complete Record
0 Other (specify): - -
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Date(s)
of
Service:
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to
- -
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The information shall be obtained, used, or disclosed for the following purpose(s) only:
0 Insurance 0 Continued Treatment 0 Legal 0
At
the request
of
the patient/patient's representative 0 Other (spec
ify)
:-
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( 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.
Un
le
ss
revoked or otherwise indicated, the automatic expiration date
will
be
one year from the date
of
signature or
upon
occurrence
of
the
fo
llow.
• I release the entities listed above, their agents and employees from
any
liability in connection with the use or disclosure
of
the protected
health
in
formation covered
by
this autho
ri
zation. 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 as authorized by
law.
• 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
fo
r benefits, the requesting entity will not condition the
provision
of
treatment or payment for my care on my signing this authorization.
I understand
that
my
medical information may indicate
that
I have a communicable
or
venereal disease which may include, but is not
limited to, disease such as hepatitis, syphilis, gonorrhea,
or
the human immunodeficiency virus, also knows 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.
Signature
of
Patient or Legal
Representative:-
- - - - -
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Date:--
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Description
of
Legal Representative's Authority:
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Expiration Date
of
Authorizatio
n:-
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- - - -
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
di
sclosed 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 disclos
ure
of
that identifying informat
ion
is authorized
by
you,
by
an
order
of
the court, or the U.S. Department
of
Health,
or
by
law.
click to sign
signature
click to edit
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