Download Authorization For Release of Medical Record

Authorization For Release of Medical Record Information
Date: __________________________________________
Name of Patient: _________________________________
Medical Record Number: __________________________
Address: ________________________________________ City, State, Zip: __________________________________
Date of Birth: ____________________________________ Telephone Number: _______________________________
PLEASE RELEASE THE MEDICAL RECORDS FROM:
X MacNeal Hospital
3249 S. Oak Park
Berwyn, IL 60402
P: 708-783-3090
F: 708-783-3171
INFORMATION REQUESTED: (Check all that apply)
☐ Medical/Legal Abstract
☐ Lab Results
☐ Radiology Imaging Report/Films
☐ Discharge Summary
☐ Outpatient Report
☐ Emergency Room Report
☐ History and Physical
☐ Other (Please specify): _________________________________________________
The purpose of this release of information: _____________________________________________________________
Dates of treatment: ________________________________________________________________________________
This authorization is valid for 90 days. Authorization will expire on: ________________________________________
If your health information contains any of the following, please check all categories that apply in order to avoid delay.
By checking any of these categories, you are authorizing the release of the following information:
☐ Psychiatric/mental health or developmental disabilities information (Parent/guardian co-signature required for the release of
psychiatric information of patients 12-17 years old)
☐ HIV, AIDS and sexually-transmitted diseases diagnoses, lab results and treatment ☐ Genetic testing
☐ Alcohol/drug abuse diagnosis/treatment
METHOD OF DELIVERING INFORMATION:
☐ I will pick up the records at the above Health Information Management (Medical Record) Department.
☐ Please send an electronic copy of my medical record to:
_______________________________________________
(Name of person/business to be released to)
_______________________________________________
(Please provide email address)
☐ Please mail the records to:
______________________________________________________________________________
(Name of person/business to be released to)
______________________________________________________________________________
(Street Address, City, State, Zip Code)
______________________________________________________________________________
(Telephone/Fax Number)
☐ I will review my original record onsite at the above facility indicated in the Health Information Management (Medical Record)
Department. I will call to arrange a time to do so at the above facility.
Authorization For Release of Medical Record Information
IF YOU ARE NOT THE PATIENT:
Please print your name:
____________________________________________________________
Please state your relationship to patient: ____________________________________________________________
What gives you authority to receive the patient's information?
☐ Written patient authorization (please attach)
☐ You are the patient's parent or guardian (please attach evidence)
☐ You are the patient's Health Care Power of Attorney (please attach evidence, such as a medical power of attorney)
☐ The patient is deceased and you are the personal representative of the patient's estate (please attach evidence)
☐ Other: ________________________________________________________________________________
I fully understand the following conditions:
1. My medical record and the information therein associated with the dates of treatment and/or hospitalization stated above
may contain mental health, developmental disabilities, alcohol/substance and/or AIDS/HIV test results. (see below)
2. The medical record and/or medical information that are to be released herein are privileged and confidential and may be
released only by proper authorization, except as required by law.
I have the right to a copy of my medical record and to inspect the information and to revoke this authorization at any time by
submitting a written revocation to facility address above or presenting it in person to the Medical Records Department of the
facility listed above. In the event of revocation, any prior use of any information up to that date of revocation may not be
retracted.
CHARGES FOR INFORMATION:
I understand that I may be charged for the copies as follows:
 Written medical records will be copied at an allowable charge.
 Any other types of records can be provided at a charge to be disclosed before copying.
 All information mailed will be subject to actual postage or other delivery fees.
I understand that I may be charged for the copies of records I have requested and for postage. I agree to pay the total charges
when I pick up the copies or, if the copies are to be mailed to me, I agree to pay the invoice charges.
I understand I may request a copy of the facility's Notice of Privacy Practices or ask any other questions by calling this facility's Medical Records
Department at any time in order to learn more about how information about me is used or disclosed by the facility or about revocation of this
authorization. I understand the facility may not and will not deny or condition my health care treatment or payment for services, upon my signing
this authorization for the requested use and disclosure.
_____________________________________________________________________
Signature
________________________
Date
_____________________________________________________________________
Parent/Legal Guardian Signature
________________________
Date
This information has been disclosed to you from records whose confidentiality is protected by Federal Law. Federal regulations prohibit you from making any further
disclosure of it without the specific written consent of the person to whom it pertains, or as otherwise permitted by such regulations. A general authorization for the
release of medical or other information is NOT sufficient for this purpose. Under the Federal Act of July 1, 1975, Confidentiality of Alcohol and Drug Abuse Patient
Records, no such records nor information from such records may be further disclosed without specific authorization of such redisclosure.