Alexander Student Health Center
Authorization for the Release of Medical Information

 


 

Name: ______________________________________________     Date of Birth: _____________________

I hereby authorize the ____________________________________________ to release the protected health information indicated below to:

Name _________________________________________         Phone Number ________________________

Address_________________________________________

________________________________________________

Requested Information

I authorize the disclosure of the following types of records created from ______ to ______: NOTE: You will be charged $.10 per page for paper records.

Billing Records Pathology Reports
Radiology Reports Entire designated record set
Lab Reports Other______________________________________________________
X-rays Information created or received from other providers (Specify which ones or "all")___________________________________________________

Purpose of the Requested Use or Disclosure
The purpose of the use or disclosure is (indicate specific reason.):_________________________________

________________________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

Expiration Date
This authorization will automatically expire:

___/___/___ (May not exceed 12 months from the date of the signature below.)
when the following event occurs: __________________________________________

The facility, the employer, its employees, agents, trustees, and officers and the attending physician are released from legal responsibility or liability for the release of the above information to the extent indicated and unauthorized by this release.  I understand this authorization can be revoked at any time except for any disclosure already made in good faith, in reliance on this release.  I realize by the receipt or authorized release of these records that I am accepting responsibility for the protection of my own right of medical record confidentiality. 

Please Note the Following:

1.  You may refuse to sign this authorization.  Your refusal will not affect your ability to obtain treatment or payment.

2.  If the person(s) or entities who are authorized to receive the information above are not health care providers or health plans covered by federal health privacy laws, they may re-disclose the information and those laws would no longer protect the disclosed health information.

3.  Once you sign this authorization, we can rely on it until you revoke it or, if you have not revoked it, until it expires.  You can revoke this authorization by delivering a dated and signed letter to our clinic addressed to: Director, Alexander Health Center, 800 South Tucker Dr., Tulsa, Oklahoma, 74104-3189

4.  I acknowledge that the law of the State of Oklahoma provides that the information authorized for release may include records which indicate the presence of a communicable or venereal disease including, but not limited to, hepatitis, syphilis, gonorrhea, and the human immunodeficiency virus, also know as Acquired Immune Deficiency Syndrome (AIDS) and/or mental health information.

5. If checked, we will receive compensation for our use/disclosure of the information that is the subject of this authorization.

Signature:___________________________________________    Date:____________________
                      (of Patient or Legal Representative)

Capacity of Legal Representative (if applicable)*_______________________________________
*May be requested to provide verification of representative status. 

 

08/05/2003
Retain for 6 years