Authorization for Release of Health Information
Signature Medical Group of KC, P.A.
Patient’s Full Name
Former Name(s) (where applicable)
Soc. Sec. No.
Date of Birth
Phone
Fax
I, or my personal representative, hereby authorize Signature Medical Group of KC, P.A. (Signature) to use or disclose protected health information regarding my care and treatment. I understand that:
Information relating to
ALCOHOL/DRUG ABUSE, MENTAL HEALTH TREATMENT, GENETIC TESTING
, and/or
CONFIDENTIAL HIV-RELATED INFORMATION
will not be disclosed unless I specifically authorize such disclosure by placing my initials in the appropriate space(s) in item 8(b).
Information that is disclosed pursuant to this authorization may be re-disclosed by the recipient and no longer protected by federal or state law. If I am authorizing the disclosure of HIV-related information, the recipient is prohibited from re-disclosing the information without authorization, unless permitted to do so under state or federal law. I have a right to request a list of people who may receive or use my HIV-related information without authorization.
I have the right to revoke this authorization at any time by providing a written notice of revocation to the provider at the address listed in item 5 below, except to the extent Signature has already relied upon this authorization.
Signing this authorization is voluntary. Signature may not condition treatment. payment, enrollment in a health plan or eligibility for benefits on my signing or refusal to sign this authorization, except in limited circumstances.
5. Provider Releasing this Information
(one provider per form)
Name
Address
Phone
Fax
6. Purpose for Release of Information
At My Request
Continuity of Care
Other
7. Person(s) to Receive this Information
Send to:
Name
Address
City
State
Zip
Phone
Fax
8. Description of Information Being Released
(a) Date(s) of service (required – list all dates)
I would like (choose one)
Last (5) years of Medical Records
Laboratory Reports
Obstetric Records
Operative Notes
Other (specify)
(b.) Include information relating to (initial beside each applicable category):
Alcohol/Drug Treatment
Mental Health Treatment
Genetic Testing Information
Psychotherapy Notes
(complete a separate authorization form for these notes)
HIV-Related Information
9. Date or event on which this authorization will end
One-Time Request
Specific Event or End Date
10. Signature:
Release signed by:
Patient
Personal Representative
Name of personal representative if signing for patient (supporting documentation required)
Specify Authority
Parent
Guardian
Healthcare Agent
Administrator/Executor
Other
By signing below I acknowledge that I have read and agree with all of the above.
Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button I understand and agree that this is a legal representation of my signature.
Date