(Covered Entity)

CMC – 704

Patient Name: _________________________________ Date of Birth: ____________________________________

Address: _____________________________________ Tel. No: ________________________________________

AUTHORIZATION TO: (Check One)

Release Patient Information to: ______________________________________________________________

Street: ________________________________ City/State:________________________________________

Request Patient Information from: ___________________________________________________________

Street: ________________________________ City/State:________________________________________

DATES OF SERVICE for patient information to be released or received: _______________ to _______________.

PATIENT INFORMATION to be released or received: (Check All That Apply)

ED Visit Cardiac Testing Laboratory Tests Medical Images (report only) Office Notes

Abstract (Discharge, Summary, History & Physical, Procedures, Consults, plus the above items).

Other: (Please Specify) ________________________________________________

SENSITIVE INFORMATION: (Please Initial) Behavioral Health _____ HIV/AIDS _____ Drug or Alcohol

_____

PURPOSE for which this patient information is being requested/ released: (Check One)

Continued Medical Care Transferring Out of Practice Other: (Please Specify) ___________________

I understand that I may inspect or obtain a copy of the protected health information described by this Authorization.

I understand that Catholic Medical Center shall not condition treatment on my providing authorization for the requested

use or disclosure AND THAT I MAY REFUSE TO SIGN THIS AUTHORIZATION.

I understand that this Authorization may be revoked in writing and the written revocation must be delivered to the

Medical Records Department, revocation will not be effective for the disclosure of records whose release I had

previously authorized, or where other action had been taken in reliance on a valid authorization.

I understand that information used or disclosed pursuant to this Authorization could be subject to redisclosure by the

recipient and, if so, may not be subject to federal or state law protecting its confidentiality.

I understand that it is my sole responsibility to safeguard any of my protected health information provided to me directly,

and that Catholic Medical Center has not encrypted or otherwise protected any electronic media provided to me with my

health information and shall not be liable for any subsequent acquisition, access, use or disclosure.

EXPIRATION DATE: This Authorization is valid until: (Insert date/event no later than one year from now) _________

(If no date/event is stated, this Authorization expires one year from the date it was signed.)

___/___/___ ____:____ _________________________________ ___________________________________

Date Time Signature of Patient or Representative Relationship of Representative, if applicable

COPY PROVIDED: If requested, CMC shall provide a copy of this signed Authorization to the subject individual.

** This information has been disclosed to you from records whose confidentiality is protected by Federal confidentiality rules (42 C.F.R.

Part 2). The Federal rules prohibit you from making any further disclose of this information without the specific written consent of the

person to whom it pertains or as otherwise permitted by 42 C.F.R. Part 2. A general authorization for the release of medical or other

information is not sufficient for this purpose. The Federal rules restrict any use of the information to criminally investigate or prosecute

any Alcohol or Drug abuse patient. (42 C.F.R. §2.32)

AUTHORIZATION

TO RELEASE OR REQUEST

PROTECTED HEALTH INFORMATION

Please Check One:

 Pick Up: __ Paper Copy __ eCopy

 Mail

 Fax (to other Providers only): _____________