Download uthorization for Disclosure of Health Information

Authorization for Disclosure of Health Information
320 East 2nd Street – Libby, MT 59923
Phone: 406-283-6900 Fax: 406-293-6622
Please email Dental Images to [email protected]
I, __________________________________
(Print Patient Name)
____________________
DOB
Hereby authorize______________________________________
___________________
____________
(City & State)
(Phone)
(Name of Facility)
To provide to ___Northwest
____________________________
Social Security Number
Community Health Center_______________________________
(Name of Individual or Facility)
_____320 E 2nd St, Libby, MT, 59923______________________________
(Street, City, State, Zip)
__406-283-6900___________
(Phone Number)
The health information specified below:
Purpose: Continuity of Care_____ Self____ Other________________________________________
Covering the period from:__________________ to ____________________
Information to be disclosed
___Hospital
___Progress Notes
___Complete Record
___Behavioral Health
___Consult Notes
___Laboratory Tests
___Pathology Reports
___Billing
___Imaging Reports ___Dental Images
___Consultation Reports
___Other(please specify)_________________________________________________________________
I understand that my health record may include information relating to sexually transmitted disease, acquired
immunodeficiency Syndrome (AIDS), or human immunodeficiency virus (HIV). It may also include information about
behavioral or mental health services, and treatment for alcohol or drug abuse.
I understand this authorization may be revoked in writing at any time, except to the extent that action has been
taken in reliance on this authorization. Unless, otherwise revoked or specified, this authorization will expire six (6)
months from the date signed. I understand there may be a charge for copying records, and that it may take at least
ten (10) business days to process this request.
This facility, its employees, officers and physicians are hereby released from any legal responsibility or liability for
disclosure of the above information to the extent indicated and authorized herein. I understand that any disclosure
carries with it the potential for an unauthorized re-disclosure and that the information may not be protected by
federal confidentiality rules. If I have questions about disclosure of my health information, I can contact the Health
Information/ Privacy Officer at Northwest Community Health Center. I understand this authorization is voluntary,
and not necessary to obtain healthcare services.
Signature of Patient or Legal Representative __________________________________Date:__________________
Printed Name AND relationship to Patient_____________________________________________________________
Expiration Date/Event Specified by Patient (no more than 24 months)___________________ID Verified?
Photo________ Known______ Witnessed by_______________ Date & Time Witnessed:_______________