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Records Release

This document authorizes the use and disclosure of a patient's health information. It specifies the patient's name and identifying information, describes the health information to be disclosed as records from the past six months, and lists the parties authorized to release and receive the information. The patient understands that the disclosed information may include details about alcohol, drug abuse, mental health, or sexually transmitted diseases. The authorization will expire at a specified date or event, and the patient may revoke the authorization in writing, though any prior disclosures cannot be revoked. Treatment will not be conditional on providing authorization except for research or creating third party information.

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Chad Martin
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135 views1 page

Records Release

This document authorizes the use and disclosure of a patient's health information. It specifies the patient's name and identifying information, describes the health information to be disclosed as records from the past six months, and lists the parties authorized to release and receive the information. The patient understands that the disclosed information may include details about alcohol, drug abuse, mental health, or sexually transmitted diseases. The authorization will expire at a specified date or event, and the patient may revoke the authorization in writing, though any prior disclosures cannot be revoked. Treatment will not be conditional on providing authorization except for research or creating third party information.

Uploaded by

Chad Martin
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Authorization for Use and Disclosure of Information

I hereby authorize the use and disclosure of my individually identifiable health information as described below; I
understand that this authorization is voluntary. I understand that information used or disclosed pursuant to this
Authorization may be disclosed by the recipient and may no longer be protected by the federal privacy regulations.

Patient Name: _______________________________________________(Print)

DOB: _________________________

ID Number or SSN: __________________________________


Specific description of information to be used or disclosed:

Please send records for the last six (6) months only unless there are specific circumstances.
Purpose of use or disclosure of health information: _________________________________________________

Persons/Organizations authorized to release the information:________________________________________

Persons/Organizations authorized to receive the information: ________________________________________

I understand that the disclosure of my personal health information may include information regarding
diagnosis and/or treatment for any of the following: alcohol/drug abuse, psychiatric or mental illness,
and/or sexually transmitted diseases, including Human Immunodeficiency Virus (HIV) or (AIDS virus).
I understand that this authorization will expire _________________________________ OR at the following described event
that relates to the purpose of disclosure.
Describe event: _____________________________________________________________________________
I understand that I may revoke this authorization at any time by notifying my physician in writing at Cockrell
Family Medical Center, P.C., but if I do revoke my authorization, my revocation is not effective to the extent my
physician has relied on this Authorized before receiving my revocation.

I understand that my physician will not condition my treatment, payment, or enrollment in a health plan on
whether I provide authorization for the use and disclosure described above except:
If my treatment is related to research
If healthcare is provided to me solely for the purpose of creating protected health information for
disclosure to a third party
I understand that there may be a fee for preparing and furnishing this information.

Patient/Representative Signature: ______________________________________ Date: _________________

Printed name of patients representative: _________________________________________________________


Relationship to patient: _______________________________________________________________________

Cockrell Family Medical Center


120 Norfleet Drive Senatobia, MS 38668
(662) 301-1128 Phone (662) 301-4430 Fax

*Please do not FAX more than 20 pages*

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