DH3203-SSG-09/2017
AUTHORIZATION TO DISCLOSE
CONFIDENTIAL INFORMATION
INFORMATION MAY BE DISCLOSED BY:
Person/Facility: ____________________________________________________________________ Phone #: ___________________________
Address: __________________________________________________________________________
INFORMATION MAY BE DISCLOSED TO:
Person/Facility: ____________________________________________________________________ Phone #: ___________________________
METHOD OF DISCLOSURE:
______ Pick up at Clinic/Facility
______ Address: __________________________________________________________________________
______ Fax #: _____________________________
______ Email Address: (please note that emailing may not be a secured method of communication)
_________________________________________________________________________________________
INFORMATION TO BE DISCLOSED: (Initial Selection)
_____ General Medical Record(s), including STD and TB _____ Progress Notes _____ History and Physical Results
_____ Immunizations _____ Family Planning _____ Prenatal Records _____ Consultations
_____ Diagnostic Test Reports (Specify Type of test(s) _____________________________________________________________________
_____ Other: (specify) _______________________________________________________________________________________________
I specifically authorize release of information relating to: (initial selection)
_____HIV test results for non-treatment purposes _____Substance Abuse Service Provider Client Records
_____
Psychiatric, Psychological or Psychotherapeutic notes _____Early Intervention _____WIC
PURPOSE OF DISCLOSURE:
_____ Continuity of Care _____ Personal Use _____ Other (specify)__________________________________________________________
EXPIRATION DATE: This authorization will expire (insert date or event) _______________. I understand that if I fail to specify an expiration
date or event, this authorization will expire twelve (12) months from the date on which it was signed.
REDISCLOSURE: I understand that once the above information is disclosed, it may be redisclosed by the recipient and the information may not
be protected by federal privacy laws or regulations.
CONDITIONING: I understand that completing this authorization form is voluntary. I realize that treatment will not be denied if I refuse to sign
this form.
REVOCATION: I understand that I have the right to revoke this authorization any time. If I revoke this authorization, I understand that I must do
so in writing and that I must present my revocation to the medical record department. I understand that the revocation will not apply to information
that has already been released in response to this authorization. I understand that the revocation will not apply to my insurance company, Medicaid
and Medicare.
________________________________________________________ _______________________________________________
Client/Legal Representative Signature Date
________________________________________________________ _______________________________________________
Printed Name Legal Representative’s Relationship to Client
DH3203-SSG-09/2017
________________________________________________________ _______________________________________________
Witness (optional) Date
If you are a legal representative of the person whose information you are requesting, you must provide documentation proving your legal authority to
the request this information (for example, power of attorney, healthcare surrogate form, order, appointment of a guardianship, order appointing
personal representative, letters of administration).
Client Name: ________________________________
ID#: ________________________________
DOB: ________________________________
Original: To File Copy: To Client Copy: To Accompany Disclosure
