Risk Management

Authorization For Use or Disclosure of Health Care Information

Patient name: ___________________________________________________________________________

Date of birth:______________________________              SSN: ______________________________

I.  My Authorization

You, [insert physician or practice name], may use or disclose the following health care information:

 All my health information maintained by you

 My health information relating to the following treatment or condition: _________________________________

 My health information for the date(s):____________________________________________________________

 Other:_____________________________________________________________________________________

You may disclose this health information to:

Name (or title) and organization__________________________________________________________________

Address: _________________________________City ________________________State _________Zip_______

Reason(s) for this authorization (check all that apply):                          

This authorization ends:          on (date) __________________

 when the following event occurs _____________________________________

II.  My Rights

I understand I do not have to sign this authorization in order to receive treatment.  However, I may be required to sign this authorization form:

• To take part in a research study; or
• To receive health care when the purpose is to create health information for a third party.

I may revoke this authorization at any time, in writing, sent to [insert physician or practice name] at the address provided below.   If I do, it will not affect any actions already taken by [insert physician or practice name] based upon this authorization; uses and disclosures already made cannot be taken back.  I may not be able to revoke this authorization if its purpose was to obtain insurance.

• [insert physician or practice address]

Once the office discloses health information, the person or organization that receives it may re-disclose it.  Privacy laws    may no longer protect it.

I will receive a copy of this authorization after I have signed it. A copy of this authorization is as valid as the original.

___________________________________________          __________________            ____________________

^{Patient or legally authorized individual signature                                   Date                                                          Time}

Patient is unable to sign because of:_______________________________________________

                                                                        ^{Age of minor or reason for patient’s inability to sign}                

___________________________________________            ______________________________________________

^{Printed name if signed on behalf of the patient                                                  Relationship & Authority (parent, legal guardian, personal representative, etc.)}

III.  Additional Consent for Certain Conditions

This medical record may contain information about physical or sexual abuse, alcoholism, drug abuse, sexually transmitted diseases, abortion, or mental health treatment.  Separate consent must be given before this information can be released.

___ I consent to have the above information released.

___ I do not consent to have the above information released.

___________________________________________          __________________            ____________________

^{Patient or legally authorized individual signature                                   Date                                                          Time}

IV.  Additional Consent for HIV/AIDS

This medical record may contain information concerning HIV testing and/or AIDS diagnosis or treatment.  Separate consent must be given to have this information released.

___ I consent to have the above information released.

___ I do not consent to have the above information released.

___________________________________________          __________________            ____________________

^{Patient or legally authorized individual signature                                   Date                                                          Time}