Authorization to Transfer Health Care Information

 

 Patient’s Name ____________________________________________  Date of Birth  ____________________

 

            I HEREBY REQUEST AND AUTHORIZE THE FOLLOWING RELEASE AND TRANSFER OF INFORMATION:

 

            INFORMATION TO BE RELEASED BY:                      INFORMATION TO BE RELEASED TO:

 

                NAME:________________________________                        NAME:__________________________________

 

                ADDRESS:_____________________________                       ADDRESS:_______________________________

               

                _______________________________________                    _________________________________________

                               

                _______________________________________                    _________________________________________

                (city,state,zip)                                                                                       (city,state,zip)

                PHONE:_______________________________                        PHONE:__________________________________

 

 

                GENERAL MEDICAL INFORMATION:

                                                Dates from/to:                                                                      Dates from/to:     

 

                [  ]  All health care information________________________                [  ]  Other:__________________________

 

                [  ]  Relating to the following treatment or condition

               

                       _______________________________________________

 

                ________________           _______________________________________     ____________________________

                Date                                        Signature of patient or authorized representative                          Relationship to patient if not patient

               

RELEASE REQUIRING SPECIAL CONSENT:            

                My signature below specifically authorizes the release of healthcare  information relating to testing, diagnosis or treatment  for:

 

                [  ]  HIV/AIDS Virus__________________________________       [  ]  Mental Health/Psychiatric Disorders___________________________

 

                [  ]  Sexually Transmitted Diseases______________________       [  ]  Drug, Alcohol Abuse/Treatment_______________________________

 

                 ___________________         _________________________________________________              ____________________________________

                Date                                        Signature of patient or  authorized representative                         Relationship to patient if not patient

 

CONSENT OF MINOR:

 

                A minor patient’s signature is required in order to release information concerning care  for:  (1) conditions relating to the  minor’s

                sexuality including, but not limited to, contraception, pregnancy and pregnancy termination, sterilization, and sexually transmitted

                diseases (age 14 and above), (2)  alcoholism and/or drug abuse (age 13 and above), (3) mental health conditions (age 13 and above).

 

                ____________________        _________________________________________________

                Date                                        Signature of patient

 

 

 

 

 

This authorization expries 90 days after the date  it  is signed.  There may be charges associated with your request for records. Identification may be required before releasing information.  This authorization may be revoked in writing.