AUTHORIZATION TO USE AND DISCLOSE PROTECTED HEALTH INFORMATION
Patient
Patient Name: ________ I
___ Print
___________________ 01/05/1925
OB: _____________Medical 231545
Record #_______________
49 MacArthur Rd Pueblo
Address: ____________________________________________________ CO 81001-1774
_________________
(719)-555-7777
___________________________E-mail lharmonson@verisma.com
Address___________________________
Patient Print
I, ______________________________________, CBC Clinical Trialworks
authorize _____________________________________________________
(Patient or Legal Representative) (Name of physician / health care provider releasing records)
to disclose to:
Patient Print
Name: ___________________________________________________________________ (719)-555-7777
Phone: ____________________
49 MacArthur Rd Pueblo
Address: ___________________________________________________________________ CO 81001-1774
_________________
Only the following specific information (check all that apply):
Abstract Operative Reports EKG/EEG Reports
History and Physical Radiology Reports Cardiac Testing (Holter, Echo, Stress, etc.)
Discharge Summary Laboratory Reports Behavioral Health/Psychiatric Care
Consultations Pathology Reports Immunization Records
Progress Notes Clinic Records Billing Records
ER Record Therapy Notes/Reports Other
!_________
Or:
Entire Medical Record for specified date(s) of service: From: _____________________To:___________________
Or:
Entire Medical Record
Information to be release by: Electronic Download Pick Up at Facility * + Print & Mail
I understand that information disclosed pursuant to this authorization may include information relating to the following, unless
specifically restricted 0 1 1below:
&2 &* 32 * & & 03 2 *
✘
HIV/AIDS diagnosis and/or testing Sexually transmitted disease(s) diagnosis and/or testing
Genetic testing
I am a patient requesting my medical records
The purpose of the disclosure is: __________________________________________________________________________
Redisclosure of Information: I understand that once information is disclosed pursuant to this authorization that the Health Insurance
Portability and Accountability Act of 1996 (HIPAA), 45 C.F.R. Parts 160 and 164, protecting health information may not apply to the recipient
of the information and, therefore, may not prohibit the recipient from re-disclosing it. Other laws, however, may prohibit redisclosure.
Right to Refuse to Sign this Authorization: I understand that generally the person(s) and/or organization(s) listed above who I am authorizing
to use and/or disclose my information may not condition my treatment, payment, or eligibility for health care benefits on my decision to sign
this authorization.
Right to Revoke: I understand that I may revoke this authorization in writing at any time except to the extent that action has been taken in
reliance on it, or unless this authorization is given as a condition of obtaining health insurance coverage and the insurer has a legal right to
contest the policy or a claim under the policy. To revoke this authorization, I will provide the Privacy Officer at the above listed
physician/health care provider’s office with a written revocation.
Right to Inspect: I understand that I have the right to inspect the health information I have authorized to be used or disclosed by this
authorization form.
Right to Receive a Copy of Authorization: I understand that if I agree to sign this authorization, I must be provided with a signed copy of this
form if I so request.
05/07/2017
Expiration Date: This authorization is in effect until __________________ (I understand that unless I provide a written revocation at an
earlier date, this authorization will expire on the above date.)
02/06/2017
Date: _______________
Revised 7/11/2016
