AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION

AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION

Release of records – FROM Family Health West (FHW)
PATIENT: I, (First Name, Last Name)*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Email address
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
I hereby authorize Family Health West to release my protected health information described below which may include information concerning treatment for drug or alcohol use, psychiatric treatment, HIV/AIDs/ARC status or genetic testing.*

YesNo
TO:
Name*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Fax Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Release by method of

emailfaxmailpick up
On media type

CDUSBPaper
Due Date

MonthDayYear
Date
If email, choose:

encyrptedunencrypted
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)
Date(s) of Test/Visit*

MonthDayYear
Date
Why is the record being requested?
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.Format: (000) 000-0000.
Name of your designated representative*
Please Release the following information:
Records starting on:*

MonthDayYear
Date
And ending on:*

MonthDayYear
Date
Provider:*
Please release the following (select all that apply)*

Discharge SummaryOperative ReportSleep Study ReportClinic Note (specify clinic name below)Emergency Room/Urgent CareEKG/Stress Test ReportTherapy Note (specify below)Immunization RecordLaboratory ReportRadiology ReportRadiology Image (specify below)Complete Record
Clinic Name*
Therapy Note - *Specifically*

PTSTOT
Radiology Image - *Specifically by:*

emailUSBCD
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
If I check a box below, I request that you DO NOT send the following records:

I do not authorize release of any records concerning drug or alcohol treatmentI do not authorize release of any records concerning psychiatric treatment/behavioral health services/counseling servicesI do not authorize release of any records concerning genetic testingI do not authorized release of any records concerning my diagnosis of or treatment for HIV, AIDS, ARC, or that contain some other reference to my identity as an HIV, AIDS or ARC patient.
This authorization will expire once the purpose stated above is served.
I understand that information used or disclosed pursuant to this authorization could be subject to re-disclosure by the recipient and, if so, may not be subject to federal or state law protecting its confidentiality.

I understand that I may inspect or receive a copy of the protected information described in this authorization.

I understand that this authorization may be revoked at any time by notifying FHW in writing to: Family Health West ATTN HIMS at 300 West Ottley Avenue, Fruita, CO 81521, and that FHW must cease using this authorization, except that FHW may complete any actions it initiated in reliance on this authorization and prior to my revocation.

I understand that FHW shall not condition treatment, payment or enrollment in the health plan or eligibility for benefits on my providing authorization for the requested use or disclosure and that I may refuse to sign this authorization.

I understand that by authorizing this release of my medical records, I also release FHW from all legal responsibility or liability that may arise from the release of my protected health information.
Signature of Individual or Personal Representative*

Clear
Date*

MonthDayYear
Date
Authority of Representative (parent of minor, court appointed guardian, medical power of attorney)*
**Please allow 10 business days to process this request.

If required sooner, please specify a due date above.
Should be Empty:

AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION

**Please allow 10 business days to process this request.