Authorization for Release of Patient Information

Authorization for Release of Patient Information

Family Health West
Your Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
I Authorize the following individual or organization:*

Family Health WestOther
You Chose Other, please specify here
To release information to:
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Fax Number
Please enter a valid phone number.
When my records are ready, please:*

Mail/fax the records requestsCall me on the number providedAllow my designated representative to pick upOther/Email Me (please provide your email address)
When my records are ready, please:*

Mail/fax the records requestedCall me on the number providedAllow my designated representative to pick them upOther/Email (please provide email address)
Phone Number to call*
Please enter a valid phone number.
Name of your designated representative*
Please Release the following information:
Records starting on:*

MonthDayYear
Date
And ending on:*

MonthDayYear
Date
Provider:*
Select they type of records you would like released.*

Complete ChartImaging ReportsImaging CDsDischarge SummaryTherapy NotesHistory & PhysicalLaboratory ReportsDoctor's OrdersDoctor's NotesMedication ListConsultation ReportsOperative ReportOther
Select the type of Therapy Notes you would like released

Physical TherapySpeech TherapyOccupational Therapy
Release of records is for the purpose of:*

Personal RecordsMarketing that involves paymentAt the request on the IndividualOther
I request and authorize the release of information to the individual or organization named above. I understand that I have a right to 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 FHW Health Records Department. I understand that the revocation will not apply to information that has already been released in response to this authorization. Unless otherwise revoked, this authorization will expire on the following date, event, or condition: blanks . If I fail to specify an expiration date, event, or condition, the authorization will expire in six (6) months.
I understand that 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 receive treatment. I understand that I may inspect or copy 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 re-disclosure and the information may not be protected by federal confidentiality rules. If I have questions about the disclosure of my health information, I may contact the Privacy Officer.
Today's Date*

MonthDayYear
Date
Signature of Patient/Guardian/Power of Attorney*

Clear
Description of your authority to represent the individual*
Should be Empty: