Download the Medical Information Release Authorization form
Download the Medical Information Release Authorization form
Download the Medical Information Release Authorization form
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I understand that this authorization is valid only for a maximum of 90 days from <strong>the</strong> date below, and it coversonly treatment prior to <strong>the</strong> date below.This in<strong>form</strong>ation may be released by facsimile machine if request warrants. Commonwealth HealthCorporation and its subsidiaries are hereby released from any liability and <strong>the</strong> undersigned will holdCommonwealth Health Corporation harmless for complying with this authorization. A photostat copy of thisauthorization is acceptable and will be treated as original.The undersigned acknowledges that <strong>the</strong> provision of free medical records by any healthcare provider whoreceives this release shall fulfill that healthcare provider’s obligation to provide one free copy of <strong>the</strong> medicalrecords, and that any future report request for medical records from <strong>the</strong> healthcare provider may result in acopying fee up to one dollar per page.I understand that <strong>the</strong> in<strong>form</strong>ation in my health record may include in<strong>form</strong>ation relating to sexually transmitteddisease, acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV). It may alsoinclude in<strong>form</strong>ation about behavioral or mental health services, and treatment for alcohol and drug abuse.I understand that I have a right to revoke this authorization at anytime. I understand that if I revoke thisauthorization I must do so in writing and present my written revocation to <strong>the</strong> Health <strong>In<strong>form</strong>ation</strong> ManagementDepartment. I understand that <strong>the</strong> revocation will not apply to in<strong>form</strong>ation that has already been released inresponse to this authorization. I understand that <strong>the</strong> revocation will not apply to my insurance company when<strong>the</strong> law provides my insurer with <strong>the</strong> right to contest a claim under my policy.Revocation date__________________ Patient/Legal Representative:______________________________I understand that authorizing <strong>the</strong> disclosure of this health in<strong>form</strong>ation is voluntary. I can refuse to sign thisauthorization. I need not sign this <strong>form</strong> in order to assure treatment. I understand that I may inspect or copy <strong>the</strong>in<strong>form</strong>ation to be used or disclosed, as provided in CFR 164.524. I understand that any disclosure ofin<strong>form</strong>ation comes with it <strong>the</strong> potential for an unauthorized redisclosure and <strong>the</strong> in<strong>form</strong>ation may not beprotected by federal confidentiality rules. If I have questions about disclosure of my health in<strong>form</strong>ation, I cancontact <strong>the</strong> Health <strong>In<strong>form</strong>ation</strong> Management Department.Patient/Legal Representative Signature: ____________________________________ Date:_____________Relationship to patient:__________________________________Please mail <strong>the</strong> completed authorization <strong>form</strong> to:Attn: <strong>Release</strong> of <strong>In<strong>form</strong>ation</strong>Health <strong>In<strong>form</strong>ation</strong> Management DepartmentThe <strong>Medical</strong> Center250 Park StreetBowling Green, KY 42101FOR OFFICE USE ONLY <strong>Release</strong>d by: ____________________________________ # of pages copied: ______________First free copy: Yes No MEDICAL INFORMATIONRELEASE AUTHORIZATIONPage 2 600195 (245) Rev. 9/11