Authorization for Use or Disclosure of Protected Health Information

Patient Name*

Address*

DOB*

Phone*

Email*

I, or my authorized representative, request and authorize the release of my health information as set forth on this form.

Release Information From :

Name of Provider or Individual*

Address*

Release Information To :

Name of Provider or Individual*

Address*

I request that you release the following: (initial next to all that apply):*

release my entire medical record (all protected health information)

release only the following items from my medical record (please specify below):

Only the following Medical Records Should be Released:

Please answer if you selected "release only the following items from my medical record"

Check here to indicate how you want your records to be transferred:*

Paper

Fax

Email Address or Fax Number to send records to if selected above

For security purposes, we will only be able to email records to the email address you have on file in your chart, if you are requesting we email you your own records. The email address you enter on this form must match the email address in your chart. If you are requesting that we email your records to a third party (for example, a lawyer's office), then we may attempt to confirm the validity of that email prior to releasing the records but you remain responsible for ensuring the accuracy of the email address you enter. Please note that if we have any questions or concerns about the record request or email address, we will not email the records but will send by fax or paper. This is meant to ensure the privacy and security of your protected health information.

Fees

Please note that not all other facilities will accept records on CD or by email, and we will be unable to send them on CD or by email in this case. If you do not check any option, records will be mailed in paper form or will be faxed. By checking the email option above, you agree that you understand that email may not be secure, although EFP will only send by encrypted email to better protect your privacy. This means that there may be a risk to you that the information contained in the email could be intercepted and read by a third party. By signing this form, you indicate that you accept those risks and want EFP to email your records as indicated.

For the following to be included in your record release, please initial next to the desired item below:

including HIV

including alcohol/drug information

including records from mental health programs

including genetic testing

This protected health information is being used or disclosed for the following purposes*

Records to Specialist concerning treatment

Permanent Transfer Out of the Practice

Records to Specialist concerning treatment for

Reason*

Reason*

Insurance Change/Type of Insurance

Moving out of area

Dissatisfied with Care

Billing Issues

Other

Insurance Change/Type of Insurance*

Other*

Reason

Reason

Insurance Change/Type of Insurance

Moving out of area

Dissatisfied with Care

Billing Issues

Other

Insurance Change/Type of Insurance*

Other*

I understand that if my records contain information about alcohol and drug abuse, mental health treatment from a mental health program, genetic testing information, and/or HIV/AIDS status, I authorize the Practice to release such information as part of my medical record only if I place my initials on the appropriate line as set forth above. The disclosure of any part of the medical record deemed to be “psychotherapy notes” will require a separate authorization.

This authorization shall be in force and effect until 60 days after the date of signature at which time this authorization to use or disclose this protected health information expires unless revoked by request earlier.

Fees: The practice will waive the fee for the first copy being sent to another medical facility. Records released directly to patients will be subject to a fee of $6.50, regardless of form (paper, CD, etc). Records released to third parties will be subject to a fee of $.75/page, up to a maximum of $50, regardless of form.

Is the signer the Patient or a Personal Representative*

Patient

Personal Representative

Description of Personal Representative's Authority (e.g., legal guardian, executor, etc)

Hidden

Signature of Patient or Personal Representative

Print Name of Patient or Personal Representative*

Date*

Description of Personal Representative’s Authority (e.g., parent, legal guardian, executor, etc)*

A copy of this form will accompany your records.

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Phone

This field is for validation purposes and should be left unchanged.

Authorization for Use or Disclosure of Protected Health Information

I, or my authorized representative, request and authorize the release of my health information as set forth on this form.

Release Information From :

Release Information To :

Fees

Practice Information

Patient Resources

Primary Care Services

Ancillary Services

Contact Us

Practice Information

Patient Resources

Primary Care Services

Ancillary Services

Contact Us