AUTHORIZATION FOR USE OR DISCLOSURE OF PROTECTED HEALTH INFORMATION

Fieldset

  • AUTHORIZATION FOR USE OR DISCLOSURE OF PROTECTED HEALTH INFORMATION

    1. Print legibly in all fields using dark permanent ink.
    2. Section I, print your name or the name of patient whose information is to be released.
    3. Section II, print the name and address of the facility releasing the information. Also, provide the name of
    4. the person, facility, and address that will receive the information.
    5. Section III, state the reason why the information is needed, e.g., disability claim, continuing medical care, legal, research-related projects, etc.
    6. Section IV, check the appropriate box as applicable.
      1. Only information related to -- specify diagnosis, injury, operations, special therapies, etc.
      2. Only the period of events from -- specify date range, e.g., Jan. 1, 2014, to Feb. 1, 2014.
      3. Other (specify) -- e.g., Physician, Billing, Employee Health.
      4. Entire Record -- complete record including, if authorized, the sensitive information (alcohol and drug abuse treatment/referral, sexually transmitted diseases, HIV/AIDS-related treatment, and mental health other than psychotherapy notes).
      5. IN ORDER TO RELEASE SENSITIVE INFORMATION REGARDING ALCOHOL/DRUG ABUSE TREATMENT/REFERRAL, HIV/AIDS-RELATED TREATMENT, SEXUALLY TRANSMITTED DISEASES, MENTAL HEALTH (OTHER THAN PSYCHOTHERAPY NOTES), THE APPROPRIATE BOX OR BOXES MUST BE CHECKED BY THE PATIENT.
    7. Section V, if a different expiration date is desired, specify a new date.
    8. Section V, Please sign (or mark) and date.
    9. A copy of the completed IHS-810 form will be given to you. 
 

I.

 

II. The information is to be disclosed by:

 

And is to be provided to:

 

III.

 

IV.

 

V.

  • I understand that I may revoke this authorization in writing submitted at any time to the Privacy Officer, except to the extent that action has been taken in reliance on this authorization. If this authorization was obtained as a condition of obtaining insurance coverage or a policy of insurance, other law may provide the insurer with the right to contest a claim under the policy. If this authorization has not been revoked, it will terminate one year from the date of my signature unless a different expiration date or expiration event is stated.
  • I understand that Arcadia Radiology Medical Group will not condition treatment or eligibility for care on my providing this authorization except if such care
    is:
    (1) Research related or (2) provided solely for the purpose of creating Protected Health Information for disclosure to a third party.
    I understand that information disclosed by this authorization, except for Alcohol and Drug Abuse as defined in 42 CFR Part 2, may be subject to
    redisclosure by the recipient and may no longer be protected by the Health Insurance Portability and Accountability Act Privacy Rule [45 CFR Part
    164] , and the Privacy Act of 1974 [5 USC 552a]. 

  • This information is to be released for the purpose stated above and may not be used by the recipient for any other purpose
 

PATIENT IDENTIFICATION

 

Verification