Request for the Disclosure and Use of Protected Health Information
I, (Patient Name)
Date of Birth
Consent to and authorize:
To furnish to Rockhill Women's Care, Inc. the following medical records and information:
I understand this authorization may be revoked in writing at any time unless it's already acted upon. To revoke this authorization I must send a request in writing to: Rockhill Women's Care, Inc., Attention: Medical Records, 20 NE Saint Luke's Boulevard, Suite 310 Lee's Summit, MO 64086
This authorization expires on
or within one (1) year of the date signed if I have not provided an expiration date or event.
I authorize the release of my records: (select one):
Only records originated prior to today's date (not including today's date)
Records originated both before and after today's date (including today's date)
Records originated only after today's date (including today's date)
I understand that my information used or disclosed pursuant to this authorization may be re-disclosed by the recipient and would no longer be protected by the Privacy Regulations. A copy of this authorization shall be considered as effective and valid as the original.
Signature of Patient or Authorized Representative
– Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature.
If Authorized Representative, please also include relationship to patient