Home > Life > Medical Forms > Medical Records Release Template > New Jersey Medical Records Release Form > New Jersey Medical Records Release Form 2

New Jersey Medical Records Release Form 2

At Speedy Template, You can download New Jersey Medical Records Release Form 2 . There are a few ways to find the forms or templates you need. You can choose forms in your state, use search feature to find the related forms. At the end of each page, there is "Download" button for the forms you are looking form if the forms don't display properly on the page, the Word or Excel or PDF files should give you a better reivew of the page.
This form is provided by Saint Barnabas Health Care System to authorize the disclosure or release of one person's protected health information.

New Jersey Medical Records Release Form 2
New Jersey Medical Records Release Form 2
SAINT BARNABAS
For Office Use Only:
M.R.#
P.A.#
HEALTH CARE SYSTEM
Clara Maass Medical Center
1 Clara Maass Drive Belleville, NJ 07109
AUTHORIZATION TO DISCLOSE PROTECTED HEALTH INFORMATION
PATIENT NAME:___________________________________________________ D.O.B.:_________________________________
ADDRESS:_________________________________________________________________________________________________
TELEPHONE:______________________________________________________________________________________________
I hereby authorize The Health Information staff of Clara Maass Medical Center of Belleville, NJ to disclose my health information to:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
The information to be disclosed to and used by the above is for the following purpose:______________________________________
____________________________________________________________________________________________________________
This authorization is limited to the following dates of treatment:
FROM _____________________________________________ TO ___________________________________________________
Information to be disclosed:
EMERGENCY ROOM RECORD CONSULTATIONS COMPLETE RECORD
HISTORY & PHYSICAL EXAM PROGRESS NOTES ABSTRACT
OPERATIVE REPTS & PATHOLOGY LAB, X-RAYS & TESTS BILLING INFO.
DISCHARGE SUMMARY NURSES’ NOTES OTHER ____________________
I understand that the information to be disclosed includes my identity, diagnosis and treatment including ALCOHOL, DRUGS,
GENETIC TESTING, BEHAVIORAL OR MENTAL HEALTH SERVICES, SEXUALLY TRANSMITTED & INFECTIOUS
DISEASES, AIDS and HIV information, as applicable.
It is my intent that the use of the information furnished is prohibited for any purpose other than stated above and that the recipient is
prohibited from disclosing this information to any other party to whom disclosure is not necessary or required for the purpose stated
above.
I understand that I have the right to revoke this authorization at any time. I understand if I revoke this authorization, I must do so in
writing and present my written revocation to the Health Information Services department. I understand that this revocation will not apply
to the extent that Clara Maass Medical Center has already taken action in reliance on this authorization. This authorization will
automatically expire 120 days from the date of my signature, unless I otherwise specify that this authorization will terminate on the
following date, or concurrently with the following event or condition:_____________________________________________________.
I understand that authorizing the disclosure of this health information is voluntary. I can refuse to sign this authorization. I need not sign
this form in order to assure treatment, payment, enrollment or eligibility for benefits. I understand I may inspect or obtain a copy of the
information to be used or disclosed, as provided in 45 CFR 164.524. I understand any disclosure of information carries with it the
potential for an un-authorized re-disclosure and the information may not be protected by federal confidentiality rules. If I have questions
about disclosure of my health information, I can contact Health Information Services – Correspondence Area at (973) 450-2063.
PATIENT SIGNATURE: ____________________________________________________ DATE:__________________________
If legal representative, sign below and state relationship and authority to do so and attach the document of authority.
LEGAL REPRESENTATIVE:_________________________________________________ DATE:__________________________
RELATIONSHIP:___________________________________________________________
WITNESS:_________________________________________________________________ DATE:__________________________
ORIGINAL RECORD COPY - PATIENT
New Jersey Medical Records Release Form 2