ROID0012 (Rev 08/04/20)
Page 2 of 2
Signature of patient or patient's legal representative
Relationship to patient or representative's
authority to act for the patient, if applicable
Printed name of patient or patient's legal representative
NOTE: If the purpose of this authorization is for the use and/or disclosure of health information for a research study, and I
refuse to sign this authorization, Lovelace Health System reserves the right to deny treatment associated with such
NOTE: If the purpose of this authorization is to disclose health information to another party based on health care that is
provided solely to obtain such information, and I refuse to sign this authorization, Lovelace Health System reserves the
right to deny that health care.
A copy of this signed form will be provided to the patient.
• I understand that I may revoke this authorization at any time by notifying the facility releasing records in writing to the
Lovelace Health System, except to the extent that; action has been taken in reliance on this authorization; or
if this authorization is obtained as a condition of obtaining insurance coverage, other law provides the insurer with the
right to contest a claim under the policy or the policy itself.
• I understand that the information I authorize a person or entity to receive may be re-disclosed and no longer protected
by federal privacy regulations.
• This authorization shall be in force and effective for one year from the date of signing or until ,
at which time this authorization to disclose this protected health information expires.
For Office Use Only:
ID Verified Yes No
Type of ID P'd Driver's License Military School Other
Employee Name Date
• The person/organization authorized to use/disclose the information will receive compensation for doing so.
• I understand that this authorization is voluntary and that I may refuse to sign this authorization. My refusal to sign will
not affect my eligibility for benefits or enrollment, payment for our coverage of services, or ability to obtain treatment,
except as provided under the NOTES listed at the bottom of this form.
NOTE: Lovelace Health System recognizes a patient's rights under HIPPA to access copies of his/her health information.
There may be charges associated with processing a request and producing requested records.
RELEASE OF INFORMATION
Lovelace Medical Center
601 Dr. Martin Luther King, Jr. Avenue
Albuquerque, NM 87102