Manet Community Health Center

Authorization to Release Protected Health Information


Authorization to Release Protected Health Information

Patient Name:  

Address:  

City:  

State:  

Zip:  

Date of Birth:  

Email:  

Home Phone:  

Work Phone:  

Cell Phone:

I hereby authorize Manet Community Health Center, Inc. to send my health information from: (Please list below)

Name (of facility):  

Address:  

City:  

State:  

Zip:  

Phone:  

Fax#:  

Email:  

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:

Behavioral/Mental Health  

HIV/AIDS Results/Treatment  

Domestic Violence  

Abortion  

Genetic Testing  

Sexually Transmitted Disease  

Alcohol/Drug Abuse  

Rape Sexual Assault  

Child/Elder/Disabled Abuse  

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:

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Manet Community Health Center https://www.manetchc.org
Signature Certificate
Document name: Authorization to Release Protected Health Information
lock iconUnique Document ID: c2da0d8cc49b438be3a97ad21a7c00e005ce2cfb
Timestamp Audit
June 17, 2020 12:33 pm ESTAuthorization to Release Protected Health Information Uploaded by Stefanie Curry - stefaniecurry@comcast.net IP 73.227.241.65
June 17, 2020 1:51 pm ESTSandra McGunigle - smcgunigle@manetchc.org added by Stefanie Curry - stefaniecurry@comcast.net as a CC'd Recipient Ip: 73.227.241.65
June 17, 2020 1:53 pm ESTSandra McGunigle - smcgunigle@manetchc.org added by Stefanie Curry - stefaniecurry@comcast.net as a CC'd Recipient Ip: 73.227.241.65