Patient Information: I give permission to release the ...€¦ · Title: Microsoft Word - ROI release of info auth modified 9-4-14 docx (00000002).docx Author: pfrank01 Created Date:
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Patient Information: I give permission to release the health information of: Patient Name: ____________________________________________ Date of Birth: ________________________________________ Street Address: ___________________________________________ Last 4 numbers of SSN:________________________________ City, State, Zip: ___________________________________________ Telephone: ( ) ____________________________________ PURPOSE OF RELEASE (check reason): Request of individual/personal Continued patient care Insurance Legal purpose including discussions & proceedings Other_______________________________________________________________________ Fill in dates of treatment for records to be released: Treatment dates: From ___________________________________________________To _________________________________________________ Authorization given to patient / Date of release: via Mail Fax Other_____________ ID Verified DL/Other ID______________________ Employee Name:_______________________________________________________________________Date:____________________________________________ Healthcare Agent/POA Guardian Executor/Administrator/Attorney in Fact Spouse Parent Adult Child Affidavit Next of Kin Other: ___________________________________ Note: If minor consented for their outpatient treatment for pregnancy, sexually transmitted disease or behavioral/mental health without parental consent, the minor must sign this authorization. When the patient is a minor being treated for substance abuse, the minor must sign this authorization, regardless of who consented for treatment. Signature of Minor:_______________________________________ Print Name: ______________________________________ Date: _____________
Patient Information: I give permission to release the health information of:
Patient Name: ____________________________________________ Date of Birth: ________________________________________
Street Address: ___________________________________________ Last 4 numbers of SSN:________________________________
City, State, Zip: ___________________________________________ Telephone: ( ) ____________________________________
PURPOSE OF RELEASE (check reason): Request of individual/personal Continued patient care Insurance Legal purpose including discussions & proceedings Other_______________________________________________________________________
Fill in dates of treatment for records to be released:
Treatment dates: From ___________________________________________________To _________________________________________________
Entire Record may include records received from outside clinics, laboratories, and/or facilities participating in your care.
Authorization given to patient / Date of release: via Mail Fax Other_____________ ID Verified DL/Other ID______________________
Healthcare Agent/POA Guardian Executor/Administrator/Attorney in Fact Spouse Parent Adult Child Affidavit Next of Kin Other: ___________________________________
Note: If minor consented for their outpatient treatment for pregnancy, sexually transmitted disease or behavioral/mental health without parental consent, the minor must sign this authorization. When the patient is a minor being treated for substance abuse, the minor must sign this authorization, regardless of who consented for treatment.
Signature of Minor:_______________________________________ Print Name: ______________________________________ Date: _____________
Lancet Rheumatology and Sara Lupus Clinic, PLLC Dr. Nilamadhab Mishra 275 Executive Park Blvd., Suite 601 Winston-Salem, NC 27103 (336) 955-1838 Office (336) 955-1842 Fax
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The individual signing this form agrees and acknowledges as follows: (i) Voluntary Authorization: This authorization is voluntary. Treatment, payment, enrollment or eligibility for benefits (as applicable) will not be conditioned upon my signing of this authorization form. (ii) Effective Time Period: This authorization shall be in effect until the earlier of one year from the date signed by patient and/or legal representative or guardian for whom this authorization is made or the following specified date: (MM/DD/YYYY) ___/___/_____ (iii) Right to Revoke: I understand that I have the right to revoke this authorization at any time by writing to the health care provider or health care entity listed above. I understand that I may revoke this authorization except to the extent that action has already been taken based on this authorization. (iv) Special Information: This authorization may include disclosure of information relating to DRUG, ALCOHOL and SUBSTANCE ABUSE, MENTAL HEALTH INFORMATION, except psychotherapy notes, CONFIDENTIAL HIV/AIDS-RELATED INFORMATION, and GENETIC INFORMATION only if I place my initials on the appropriate lines above. In the event the health information described above includes any of these types of information, and I initial the corresponding lines in the box above, I specifically authorize release of such information to the person or entity indicated herein. (v) Signature Authorization: I have read this form and agree to the uses and disclosure of the information as described. I understand that refusing to sign this form does not stop disclosure of health information that has occurred prior to revocation or that is otherwise permitted by law without my specific authorization or permission. I understand that information disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and may no longer be protected by federal or state privacy laws.
Note: If the patient lacks legal capacity or is unable to sign, an authorized personal representative may sign this form. Note the relationship/authority if signature is not that of the patient (Written Proof May be Requested):
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INCLUDING (initial by any that apply):
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_____ Drug, Alcohol, or Substance Abuse Records
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_____ Genetic Information (Including Genetic Test Results)
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_____ HIV/AIDS-Related Information (Including HIV/AIDS Test Results)
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_____ Mental Health Records (Except Psychotherapy Notes)
