Authorization to Release Medical Information Form

Patient Full Name *

First

Last

Patient Date of Birth

Patient Address

Address Line 1

Address Line 2

City

State

Zip Code

Patient Phone

Print Name to Authorize

Please list the records you are authorizing for release with as much specificity as possible, including the type of record, date or date range, the specific subject matter, and the names of persons or locations. Please attach additional pages if more space is needed. You must specifically authorize the release of records relating to drug/alcohol abuse, child abuse, HIV status, genetic testing, sickle cell anemia, or mental health records. A separate authorization is required for release of psychotherapy notes.

The Adams County Communications Center (ADCOM) to release the following records, including any Protected Health Information regarding the patient that the records contain

The records listed above may be released to the following individual(s) or organization(s): *

Address

Address Line 1

Address Line 2

City

State

Zip Code

For the purpose of

OPTIONAL Authorization to Transmit via Electronic Means: I request that the records listed above be released to the recipient by fax or email, and not by U.S. mail or delivery service. I understand the records will be sent through unencrypted fax/email that is not secure and there is a risk that the records could be seen by a third party during electronic transmission, while in electronic storage, and/or upon completed delivery. ADCOM is not responsible for unauthorized access of the Protected Health Information resulting from the faxed or emailed transmission, or for safeguarding the Protected Health Information upon delivery.

Choose Method of Transmission (Choose from the drop-down menu.)

Fax Number

Email *

EXPIRATION. Unless earlier revoked, this authorization will expire, without my express revocation, one year from the date of signing, or if I am a minor, on the date I become an adult according to state law. REVOCATION. I have the right to revoke this authorization in writing at any time, except to the extent that action has been taken based on this authorization. PATIENT RIGHTS. I understand I have a right to a copy of this authorization. I have the right to inspect or copy the information to be disclosed as provided in 45 CFR 164.524. I have the right to inspect or amend my medical records as provided in 45 CFR 164.526. I have a right to an accounting of the use and disclosure of my health information to any third party as provided in 45 CFR 164.528. RE-DISCLOSURE. I understand that any disclosure of Protected Health Information carries with it the potential for unauthorized re-disclosure, and may no longer be protected by federal confidentiality rules.

SIGNATURE: I understand that authorization for the disclosure of these records and Protected Health Information is voluntary and I can refuse to sign this authorization. I understand that medical treatment, payment, enrollment, and eligibility for benefits cannot be, and are not, conditioned on whether I sign this authorization. Photocopies of this authorization may be used in lieu of the original. By typing your name below you signify your typed signature is to the same extent as if you had signed this document in ink.

Signature of Patient or Personal Representative

Date

Description of Personal Representative's Authority

YTD Total