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Delaware Authorization to Use/Disclose Protected Health Information Form

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Delaware Authorization to Use/Disclose Protected Health Information Form
Delaware Authorization to Use/Disclose Protected Health Information Form
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Form# 01022 AUTHORIZATION TO USE/DISCLOSE PROTECTED HEALTH INFORMATION
(5/14) Page 1 of 1
Patient
Name:
Date of
Birth:
MR#
(Staff to Complete):
Phone:
Address:
I would like to receive these records via Email Email
Address: ___________________________
RELEASE MEDICAL RECORDS FROM:
DISCLOSE MEDICAL RECORDS TO:
Facility or
Name:
Facility or
Name:
Department:
Department:
Address:
Address:
City/State/Zip:
City/State/Zip:
Phone #:
Fax:
Phone #:
Fax:
I AM REQUESTING MEDICAL RECORDS FOR DATES:
Abstract of Medical Record
Outpatient Clinic Note/Encounter
Labs/Pathology Reports
Pathology Slides/Blocks
Imaging Reports (x-rays, MRI, etc.)
Imaging Films
Echocardiogram Tapes
Electrocardiogram
Verbal Communication with
Health Professional
Operative Notes
History/Physical Exam
Discharge Summary
Consultation Reports
Medications
Photos
Billing Statements
Appointments/Scheduling
Other (specify below):
____________________________
Your initials are required to release the following:
Psychiatric/Psychology Notes
Psychological Evaluations & Results
Genetics Testing
HIV Reports/STD Reports
Drug/Alcohol Results
Adolescent Encounter
Please Note: If requesting an Adolescent Encounter, the
signature of the minor is required_____________________
THIS SECTION TO BE COMPLETED ONLY WHEN AUTHORIZING OTHER INDIVIDUALS ACCESS TO MY PROTECTED HEALTH INFORMATION
I am requesting that the following individual(s) have my permission to inquire about my appointments, have access to the medical information
listed above, and receive detailed information regarding my treatment:
Name:
Relationship:
Name:
Relationship:
Name:
Relationship:
Name:
Relationship:
AUTHORIZATION:
1. I may revoke this authorization at any time by notifying the “Sent FROM” organization noted above in writing.
2. I understand that my revocation does not affect any disclosures made prior to the revocation being received and processed.
3. I understand the information disclosed may be subject to re-disclosure and no longer be protected by federal or state privacy regulations.
4. I have the right to inspect or copy the information to be used/disclosed as permitted by federal law.
5. I may refuse to sign this authorization and that it is strictly voluntary.
6. If I do not sign this form, my health care and the payment for my health
care will not be affected.
7. If this authorization originated with the provider, I will receive a copy of
this form after I sign it.
Patient/Legal
Representative Signature:
Date:
Patient/Legal
Representative Printed Name:
Relationship
to Patient:
FROM:
TO:
PURPOSE OF DISCLOSURE (please specify):
Continuing care with another physician or hospital
Transfer of Care Personal Copy Other: ____________
EXPIRATION DATE OR EVENT:
(if left blank, this Authorization expires 90 days from the date signed)
Specify a date or event:___________________________________
FEES: I understand and agree that there may be costs
associated with this request in compliance with State and
Federal Copying laws. ___________ (please initial)
Delaware Authorization to Use/Disclose Protected Health Information Form
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