AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS (AND OTHER INFORMATION)
Printed Name:________________ Date of Birth:________________
Covering the dates:________________ to present.
Please check type of information to be released:
- Complete Medical Record
- Complete Billing Record
- Consultation Reports
- Laboratory Test Results
- X-ray Films/Images
- Photos / Videos
- Telephone Inquiry
- Itemized Billing Statement
- History & Physical
- Progress Notes
- X-Ray Reports
- Diagnosis Codes (DRG)
- Discharge Summary
- Insurance Information
Purpose for Request:
- Treatment or Consultation
- Request of the Patient
- Billing/Claims Payment
Where to Send / Release Information:
Name: PATTERSON LEGAL GROUP, L.C.
Address: 245 N. WACO, STE. 405, WICHITA, KS 67202
Drug and /or Alcohol Abuse, and / or Psychiatric, and/or HIV / AIDS Records Release:
I understand if my medical or billing record contains information in reference to drug and / or alcohol abuse, psychiatric care, sexually transmitted disease, Hepatitis B or C testing, HIV /AIDS, and/or other sensitive information, I agree to its release.
Check One : __ Yes __ No
Right to Revoke:
Except to the extent that action has already been taken in reliance on this authorization, at any time I can revoke this authorization by submitting a notice in writing to the Privacy Officer c/o this facility. Unless otherwise specified or revoked, this authorization will expire on the following date or event, or one year from the date of signature.
I understand the information disclosed by this authorization may be subject to the re-disclosure by the recipient and no longer be protected by the Health Insurance Portability and Accountability Act of 1996. The 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.
Signature of Patient or Personal Representative Who May Request Disclosure:
I understand that disclosure is voluntary and I do not have to sign this authorization. I understand my refusal to sign will not affect my ability to obtain treatment, payment, or my eligibility to obtain benefits. I can inspect and/or copy the protected health information to be used or disclosed, as provided in CFR 164.524. I authorize the above-referenced providers to use and disclose the protected health information specified above. I am willing that a dated and signed copy of this authorization will have the same force and effect as an original.