INFORMA
M3132
Rev. 7/19
PART A: PATIENT INFORMATION
Patient Name:
Phone:
Email:
Address:
Date of Birth:
SS# (last 4 digits):
Medical Record #:
PART B: PERSON OR COMPANY WHO WILL RECEIVE INFORMATION
Self (same info as above)
Person or Entity:
Phone:
Email:
Address:
Fax:
PART C: INFORMATION TO BE RELEASED (check all that apply)
Records or Information:
Treatment Location:
Treatment Date(s):
From
to
(please be specific)
All Treatment Dates
PART D: PURPOSE OF REQUEST
Personal
Legal
Insurance
Continuation of Care
Other (specify):
PART E: FORMAT AND DELIVERY OF INFORMATION
Format (select only one)
MyChart
Encrypted Email Paper
CD Thumb drive (flash drive) Fax
Other
Oral Communication
Delivery Method (select only one)
Electronic (MyChart, encrypted email)
Mail
In-Person Pick up(Name:
)
PART F: REVIEW AND APPROVAL
I understand that the information to be released may include reference to sensitive information related to mental and behavioral
health, genetic testing, HIV/AIDS or other communicable diseases, and drug or alcohol abuse. I specifically approve the release
of the following information that has been marked as sensitive and/or restricted (check all that apply):
Mental and Behavioral Health Substance Use Disorder Genetic Testing
I understand that I may revoke this Authorization in writing at any time, except to the extent that action has already been taken
in response to the Authorization. I understand that the information disclosed pursuant to this Authorization may be subject to
re-disclosure by the recipient and may no longer be protected under federal privacy law. I understand that I may refuse to sign
this Authorization. If I do not sign this Authorization, Duke Health will continue to provide treatment and seek payment for
services provided. Duke Health may charge a fee for providing the information specified above.
This Authorization will automatically expire one year from the date signed below unless revoked or another date or
event is written here:
Signature
Printed Name
Date
Witness Signature
ID #
Date
PART G: REPRESENTATIVE (complete if signed by personal or authorized representative)
Representative Full Name (please print)
Relationship to Patient
Phone Number
If you are not the patient or the parent of a minor patient, you MUST attach documentation of your authority to act on behalf
of the patient (Power of Attorney, Court Order, Legal Guardian Documentation, Executor/Administrator Documentation)
SEND COMPLETED FORM TO: ROI-requestor3@dm.duke.edu; Fax: 919-620-5165 OR
Duke University Hospital - HIM, DUMC Box 3016, Durham, NC 27710; For Questions Call: 919-684-1700
Place Patient Label Here
Abstract/Summary
(Discharge Summary,
Operative/Procedure
Notes, Pathology,
Laboratory, ED Notes,
Clinic Visits, Consults)
Discharge Summary
Radiology Reports
History and Physical
Consultation Report
Physical/O
ccupati
on
al Therapy
Operative Report
Immunization Recor
d
Laboratory Reports
Emergency Department Record
Pathology Reports
Clinic Visit (Specify
Provider/Clinic)
_________
Other (please specify)
____________________________________
Entire Record
Billing Records
All Duke Health
Enterprise Entities
Duke University Hospital
Duke Raleigh Hospital
Duke Regional Hospital
Duke Clinic (specify provider / location)
Radiology Images
click to sign
signature
click to edit
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click to sign
signature
click to edit
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