Authorization for Use or Disclosure of PHI "*" indicates required fields CommentsThis field is for validation purposes and should be left unchanged.Patient Name* First Last Date Of Birth* I hereby authorize HealthFirst Family Care Center to use or disclose my health information as indicated Provide information to: Obtain information from: Exchange (verbal) information with: Name/Agency*AddressFax #Phone #Date(s) of records to be obtained/releasedFrom* Month Day Year To Month Day Year Information being requested for release:*(please check all appropriate items) Medical, diagnostic, testing, and treatment information Medication list (including prior authorization documents) Current Prenatal records, copies of all lab and imaging Lab results Sexually transmitted disease (Release to include sensitive information such as HIV results and treatment) Imaging results Immunization records Growth chart Other (Please Specify) Other Information:*Reason for Disclosure:(Please check the appropriate item) Transferring care to another physician School Legal For Personal Records Other (Please Specify) Other reason for disclosure:*Patient Acknowledgements*Select exactly 4 choices. I understand that this authorization will expire one year from the signed date. A photocopy of this form will be considered as valid as the original. I may inspect this health information before it is disclosed by making an appointment to review my record. I understand my refusal to sign this authorization will not affect my right to obtain present or future treatment except where the disclosure of the information is necessary for the treatment. I may withdraw my authorization by completing another form. This withdrawal will be effective on the date of signature except to the extent action has already been taken upon it. Signature*Patient/Parent/Legal Guardian Signature (Must be 18 years or older)Please note: Mental Health notes, Psychotherapy notes, and drug and alcohol related notes (SUD) require a separate consent form for these records to be released outside of HealthFirst Family Care Center. Δ
