Authorization to Release Protected Health Information
Date of Birth:
I hereby authorize Manet Community Health Center, Inc. to send my health information from: (Please list below)
Name (of facility):
Format of information to be released:
I wish to pick up my records: (medical records will contact you when ready for pick-up)
Please specify information to be released or obtained. Check all that apply. Only checked items will be released.
Release of information regarding specific consent. The following categories of information in your medical record will not be released without your specific authorization, indicated by initialing each appropriate category:
Sexually Transmitted Disease
Rape Sexual Assault
Purpose for requested Information: Purpose
By signing this authorization, I understand that:
This authorization will remain in effect for 90 days after the above date or as specified:
Requests for copies of medical records are subject to reproduction fees in accordance with federal/state regulations
I have the right to revoke this authorization at any time. Revocation must be made in writing to the Medical Records Department. Revocation will apply to information that has already been disclosed in response to the authorization.
Treatment, payment, enrollment or eligibility for benefits many not be conditioned on whether I sign this authorization
I also understand that this information may be re-disclosed by the recipient if the recipient is not required to follow the privacy regulations or statutes.
I have read and understand the terms of this authorization.
Leave this empty:
Your legal name
Your email address
If you have questions about the contents of this document, you can email the document owner.
Document Name: Authorization to Release Protected Health Information
Agree & Sign