AUTHORIZATION TO DISCLOSE HEALTH INFORMATION
Patient Name: Cindy L. Jarrett Date of Birth: 09/ 3 0/1965
Medical Record # 1000018
1. I authorize the use or disclosure of the above named individual's health information as described below: 2. The following individual or organization is authorized to make the disclosure:
AHIMA Medical Center 123 Records Ave Chicago, IL 65062
3. The type and amount of information to be used or disclosed is as follows: (include dates where appropriate )
0 Problem list 0 Medication list 0 List of allergies
0 Immunization record □ Operative Report - 0 Anesthesiology Redords D Laboratory results
from (date) _______ to ( date) _________
OX-Ray and imaging reports from (date) _____ to (date) ____ _ 0 Consultation reports 0 Entire record
from (date)________ to ( d a te) _________
!8:!0ther __Pathology Report
11/17/2003
4. I understand that the informatlon in my health record may include information relating to sexually transmitted disease, acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV}. II may also include Information about behavioral or mental health services, and treat,nent for alcohol and drug abuse 5 ____TbisJnfonruiliQO.Jnay be disclosed to ancl_ used by the following individual or organization: Cindy L. Jarrett 2500 River Oak Drive Chicago, IL 60606 Phone: Area Code= Exercise Number Phone Number= Student's 7-digit AHIMA ID 6. I understand I have the right to revoke this authorizatlon at any time. I understand if I revoke this authorization I must do so in writing and present my written revocation to the health information management department. l understand the revocation will not apply to information that has already been released in response to this authorization. I understand the revocation will not apply to my insurance company when the law provides my insurer with the right to contest a claim under my policy. Unless otherwise revoked, this authorization will expire on the following date, event or condition: __________. ·If 1 fail to specify an expiration date, event or condition, this authorization will expire in six months. 7. I understand that authorizing the disclosure of this health information is voluntary. I can refuse to sign ihis authorization. 1 need not sign this form in order to assure treatment. I understand I may inspect or copy the informatlon to be used or disclosed, as provided in CFR 164_524. I understand any disclosure of information carries with it the potential for an unauthorized re-disclosure and the information may not be protected by �� =:-� �·I · XYX:X Signature of patient or legal representative Date
Signature of witness
If signed by legal representative, relationship to patient
Delivery Method: Walk-in
Number of Pages: One
Main Reason for Request: PAT1<;;....!JT _ Chart Location: Perm File
Powered by FlippingBook