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1600 Sixth Avenue, suite 116B, York, PA, 17403
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Home
About Us
Services
Pediatrics
Companionship
Personal Care
Skilled Nursing
Careers
Resources
Forms
Contact Us
Blog
Schedule Consultation
Home
About Us
Services
Pediatrics
Companionship
Personal Care
Skilled Nursing
Careers
Resources
Forms
Contact Us
Blog
Schedule Consultation
Authorization for Release of Medical Record Information
Patient Name:
Date of Birth:
MM slash DD slash YYYY
Home Phone:
Work Phone:
Address:
City/State/Zip:
Please Note: Copy Fee May Be Charged For Medical Records
Above listed patient authorizes the following healthcare facility to make record disclosure:
Facility Name:
Facility Phone:
Facility Address:
Facility Fax:
Facility City, State, Zip:
Dates and Type of information to disclose:
2 years prior from last date seen
Dates (Other)
Specific Information Requested
The purpose of disclosure is:
Change of Insurance or Physician
Continuation of Care (e.g., VA Med Ctr)
Referral
Other
Please specify dates:
Other please specify:
Please specify information requested:
RESTRICTIONS:
Only medical records originated through this healthcare facility will be copied unless otherwise requested. This authorization is valid only for the release of medical information dated prior to and including the date on this authorization unless other dates are specified.
I understand the information in my health record may include information relating to sexually transmitted disease, acquired Immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV). It may also include information about behavioral or mental health services, and treatment for alcohol and drug abuse.
This information may be disclosed and used by the following individual or organization:
Release To:
Address:
City, State, Zip:
Fax:
Phone:
Choose the following:
Please mail records
Please fax records
I understand I may revoke this authorization at any time. I understand that if I revoke this authorization I must do so in writing and present my written revocation to the health information management department. I understand that the revocation will not apply to information that has already been released in response to this authorization. I understand that the revocation will not apply to my insurance company when the law provides my insurer with the right to contest a claim under my policy.
Unless otherwise revoked, this authorization will expire on the following date, event, or condition:
If I fall to specify an expiration date, event, or condition, this authorization will expire 1 year from the date signed.
I understand the authorizing the disclosure of this health information is voluntary. I can refuse to sign this authorization. I need not sign this form in order to assure treatment. I understand that I may inspect or obtain a copy of the information to be used or disclosed, as provided in CFR 164.524. I understand that any disclosure of information carries with it the potential for an unauthorized redisclosure and the information may not be protected by federal confidentiality rules. If I have questions about disclosure of my health information, I contact the authorized individual or organization making disclosure.
I have read the above foregoing Authorization for Release of Information and do hereby acknowledge that I am familiar with and fully understand the terms and conditions of this authorization.
Signature of Patient / Parent / Guardian or Authorized Representative
(Guardian or Authorized Representative must attach documentation of such status.)
Date
MM slash DD slash YYYY
Printed name of Authorized Representative
Relationship / Capacity to patient
Address and telephone number of authorized representative
Phone
This field is for validation purposes and should be left unchanged.
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