Authorization for Release of Information s5

Authorization for Release of Information

PATIENT NAME: ______LAST FIRST MI MAIDEN OR OTHER NAME DATE OF BIRTH: _____-_____-_____ SS#: _____-_____-_____ MEDICAL RECORD #: ______MO DAY YR ADDRESS: ______CITY: ______STATE: _____ ZIP: ______

DAY PHONE: ______EVENING PHONE: ______

I hereby authorize ______(Name of Provider) to release information from my medical record as indicated below to:

Arch Health Partners 15611 Pomerado Road, Suite 400 Poway, CA 92064 Phone: 858-675-3199 / FAX: 858-675-3285 INFORMATION TO BE RELEASED: DATES:  History and physical exam ______I specifically authorize the release of information relating to:  Progress notes ______ Substance abuse (including alcohol/drug abuse)  Lab reports ______ Mental health (including psychotherapy notes)  X-ray reports ______ HIV related information (AIDS related testing)  Other: ______X______SIGNATURE OF PATIENT OR LEGAL GUARDIAN DATE

PURPOSE OF DISCLOSURE:  Changing physicians  Consultation/second opinion  Continuation of care  Legal  School  Insurance  Workers Compensation  Other (please specify): ______

1. I understand that this authorization will expire on ______(Print the Date you would this Form to expire, allowing at least 30 days for us to gather, copy, and send your information).

2. I understand that I may cancel this authorization at any time. To cancel this authorization, I must notify Arch Health Partners in writing. This authorization will be cancelled once Arch Health Partners has received my written notice. The exception to this would be if my information has already been released.

3. I understand this information may have been disclosed prior to my signing this authorization. In that case, this information would not have been protected by Federal privacy regulations.

4. I understand that I am being requested to release this information by ______(Print Name of Provider) for the purpose of:______a. I understand I may see and copy the information described on this form if I ask for it, and that I will get a copy of this form after I sign it. b. I have been informed that Arch Health Partners will not receive financial or in-kind compensation in exchange for using or disclosing the health information described above. c. I understand that treatment, payment, continued enrollment in a health plan or eligibility for benefits will not be conditioned upon my authorization. 5. I understand that in compliance with California statute, I will pay a fee of $______(Print the Fee Charged). There is no charge for medical records if copies are sent to facilities for ongoing care or follow up treatment.

______OR ______SIGNATURE OF PATIENT DATE PARENT/LEGAL GUARDIAN/AUTHORIZED PERSON DATE

______RECORDS RECEIVED BY DATE RELATIONSHIP TO PATIENT

FOR OFFICE USE ONLY DATE REQUEST FILLED: ______BY: ______

IDENTIFICATION PRESENTED: ______FEE COLLECTED: $______

 REQUEST FOR RECORDS DENIED  LETTER SENT TO PATIENT BY:______

 SECOND-LEVEL REVIEW APPROVED

PP933A/3-08/Authorization for Release of Information/4/08bc