Patient #:___________________________________
Patient Name: Medical Record
#:
Date of Birth: Social Security
#:
I hereby authorize the use or
disclosure of the Protected Health Information described below to be provided
to or obtained by the following:
Name of Individual/Facility/Company to
Receive PHI Name
of Individual/Facility to Disclose PHI
Frederick
Clinic
Address: Address:
319
East Josephine, Frederick, Oklahoma
73542
Information
authorized for use or disclosure, or to be obtained:
□ All medical information concerning this
patient.
□ Medical information of this patient
compiled between to
□ Only:
Dates of Treatment, if known:
The information will be obtained,
used, or disclosed for the following
purpose(s) only:
□ Insurance □ Continued treatment □ Legal □ At the request of the patient or patient’s
representative
□ Other (specify)
I understand:
·
I may revoke this
authorization at any time, in writing, except revocation will not apply to
information already used or disclosed in response to this authorization. I may revoke this document by presenting my
written revocation as provided in the Notice of Privacy Practices. Unless revoked or otherwise indicated, the
automatic expiration date will be one
year from the date of signature or upon occurrence of the following event:
.
·
I release the entities
listed above, their agents and employees from any liability in connection with
the use or disclosure of the protected health information covered by this
authorization. The entity authorized to
disclose the information will not be compensated by the recipient for the disclosure,
except for the cost of copying and mailing as authorized by law.
·
Information used or
disclosed pursuant to this authorization may be subject to redisclosure by the
recipient and no longer protected by federal law. However, the recipient may be prohibited from disclosing substance
abuse information under the Federal Substance Abuse Confidentiality
Requirements.
·
I have the right to
inspect the health information to be released and I may refuse to sign this
authorization.
·
Unless the purpose of
this authorization is to determine payment of a claim for benefits, the
requesting entity will not condition the provision of treatment or payment for
my care on my signing this authorization.
I understand that my medical information
may indicate that I have a communicable or venereal disease which may include,
but is not limited to, diseases such as hepatitis, syphilis, gonorrhea, the
human immunodeficiency virus, and/or Acquired Immune Deficiency Syndrome
(AIDS). I further understand that my
medical information may indicate that I have or have not been treated for
psychological or psychiatric conditions or substance abuse.
___________________________________________________ ______________________________________________
Signature
of Patient or Legal Representative Date
___________________________________________________ ______________________________________________
Description
of Legal Representative’s Authority Expiration
Date of Authorization
›
Identity Verified By
(Employee Initials):
______________ Date: ________________________
___________________________________________________ ______________________________________________
Signature
of Facility Representative Date
NOTICE OF RIGHTS: Information in your medical record may indicate that you have or may have a communicable or venereal disease is made confidential by law and cannot be disclosed without your permission except in limited circumstances including disclosure to persons who have had risk exposures, disclosure pursuant to an order of the court or the Department of Health, disclosure among health care providers or disclosure for statistical or epidemiological purposes. When such information is disclosed, it cannot contain information from which you could be identified unless disclosure of that identifying information is authorized by you, by an order of the court or the Department of Health or by law.