F#245r11 (ReHf A#18&20D) Rev: 03/03/03, Rev: 08/28/13, 1/20/14, Approved: 01/31/13, 02 /25/14 I s s u e d: 03/11/14
Authorization for Use or Disclosure of Patient Information - UAB Health System
Page 1 of 2
PATIENT ACCESS/AUTHORIZATION FOR USE OR DISCLOSURE OF PATIENT INFORMATION
PatientInformation(PleasePrint)
*
RequiredforAccessRequest
*Patient Name: __________________________________
Patient SSN: _____________-_________-____________
Patient’s Phone: ( )
___________________________
Alternate Phone: ( ) ___________________________
* Patient Birthdate:
____ / ____/ ______
*
Patient’s Address:
* City, State, Zip:
Medical Record Number (office use):________________________
This authorizes the following UAB Medicine Physician/Facility/Clinic, ________________________________________________,
To provide/disclose my records specified below to
me for my personal use or 
to the party indicated below:
*Name of Person/Organization receiving my health information: ___________________________________________________________
*Street Address: _______________________________________________________________________________________________
*City: ___________________________ *State: _________________________________ * Zip Code: _________________
Phone: (_____) _____________________________________________
Fax: if applicable:(_____)_______________
____________
* Specific information requested: (Mark all that apply)
*
Patient Access Request Only
:
X
InformationType DatesofService
From
To
DischargeSummary
PathologyReport
DiagnosticProcedureReport(s)
OperativeReports(s)
FetalMonitoring
BillingRecords
RadiologyFilm(s)
Consult Report(s):
PhysicianName:
X
InformationType DatesofService
From To
FaceSheet
History&Physical
EmergencyRoomRecord
LabReport(s)
MedicationList
ClinicNotes
OtherDocuments:ListBelow:
*
NOTICE: If I request records in electronic
form, I understand that the r
ec
ords will be
encr
y
pte
d
to h
e
lp protect my privacy and the
security of my health records and that I will
be furnished with the information on how to
access those encrypted records. UAB
Health System is not responsible for the
privacy and security of the electronic records
on the CD or in an email once they are
received by the intended recipient.
MediaType:ElectronicPaper
DeliveryType:Mail
PickupCDFaxEmailtoaddressbelow:
____________________________________________
Iherebyrequest/authorizetheuseordisclosureofmyprotectedhealthinformation(“PHI”)asdescribedbelow.ThisRequest/Authorizationincludes
anyinformationrelatingtodrug, alcoholabuse/treatment,communicationswithpsychiatristsorpsychologists,and recordspertainingtosexually
transmitteddiseases,iftheyareapartofmymedicalrecord.IunderstandthatthisRequest/Authorizationisvoluntary.Oncethi
sinformationhasbeen
disclosed,it
maybesubjecttore‐disclosureandnolongerbeprotectedbyfederalregulations.
*
F# 245r11 (Ref HA# 18 & 20) Dev: 03/03/03, Rev:, 08/28/13, 1/20/14, 07/12/18 Approved:, 10/31/13, 2/25/14; Issued: 3/11/14 : Revised: 8/29/18
Authorization for Use or Disclosure of Patient Information - UAB Health System
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The patient or the patient’s representative must read the following statements:
I understand that I may revoke this Authorization at any time by notifying the entity privacy coordinator in the
writing, but
if I do, it will not be effective for disclosures made prior to my revocation in reliance on the Authorization.
I understand that UABHS may not condition the provision of treatment, payment, and enrollment in a health plan, or
eligibility for benefits on si
gning this Authorization, except under the following circumstances:
•
Participation in research projects can be conditioned on my signing an Authorization to use and
disclose PHI in the research.
•
Initial enrollment in health plans can be conditioned on signing an Authorization for the health plan to
review PHI to make eligibility determinations.
•
Furnishing healthcare services to me at the request of a third party can be conditioned on me signing
an authorization for disclosure of the PHI to the third party requesting the treatment.
This authorization will expire: _____________________________________.
If I fail to specify an expiration date or event, this authorization will expire six months from the date on which it was signed.
*
Signature of patient or patient’s representative: ___________________________________________________________
*
Printed Name of patient: _____________________________________________________________________________
*
Printed Name of patient’s representative: ________________________________________________________________
*
Relationship to the patient: ___________________________________________________________________________
*
Date: __________________________________________
(Date of event)