Download authorization for disclosure of medical records

AUTHORIZATION FOR DISCLOSURE OF MEDICAL RECORDS
SAN JUAN HEALTH PARTNERS
 Cardiology
 Aztec
Patient ID Verified: Y
 Bloomfield
 General Surgery
Verified by: __________________
 Internal Medicine and Pulmonology
 Urgent Care
Date: _______________________
 Midwifery and Women’s Health
N
MR Number: ________________
 Neurology and Neurosurgery
 Pediatrics
To maintain confidentiality, the patient or legal representative must complete bold items, sign this form and present a picture ID
I hereby authorize you to disclose the following information from the medical records of:
Patient Name: _______________________________________________________________________________________________
Date of Birth: _____________________________________________ SSN: _____________________________________________
Address: _________________________________________City: ____________________________ State: ______ Zip: ___________
Telephone: ___________________________ Time period of requested information: _____________________________________
THIS INFORMATION IS TO BE DISCLOSED
To: _______________________________________ Address: ___________________________ _____________________________
City: _____________________________________ State: ____________ Zip: __________ Telephone: _______________________
THIS INFORMATION IS TO BE DISCLOSED
From: ___________________________________________ Address: __________________________________________________
City: _____________________________________ State: _____________ Zip: __________ Telephone: ______________________
You have the right to restrict information. The information below will not be disclosed unless you check the box.
 Progress Notes
 Lab Results/Reports
 EKG/ECG
 RX Records
 Correspondence
 Radiology Reports
 Billing, Invoices and Statements
 Previous Physician Records
 Other: __________________
 HIV/AIDS Related Information  Psychological/Psychiatric Evaluation  Drug/Alcohol Related Information
REQUIRES ADDITIONAL SIGNATURE TO DISCLOSE _____________________________________________
PURPOSE FOR DISCLOSURE
 At request of individual
 For the following purposes
_________________________________________________________________________________________________________________
_______________________________________________________________________________________________________
It is further understood that the information disclosed is for the purpose stated above and may not be provided in whole or in part to any other agency,
organization or person. This information has been disclosed to you from records whose confidentiality is protected by State Law. The State Law prohibits
you from making further disclosure of such information without specific written consent of the person to whom the information pertains or is otherwise
permitted by State Law.
___________________________________________
Signature of patient or legal representative
___________________________________________
Date
________________________________________________
___________________________________________
Relationship to Patient
Witnessed by
This consent will expire one year after date of signature. You have the right to revoke this authorization at any time.