Form Bc 4761 – Fill Out and Use This PDF

Authorization to Use or Disclose Protected Health Information

I hereby authorize the above hospital(s) to use or disclose the following information from the health records of the individual whose name is described below.

Patient Name:_________________________________________	Date of Birth:___________________
(Please Print)
Address:__________________________________________________________________________________
(City)	(State)	(Zip)

Phone Number:_______________________________ Social Security #______________________________

I authorize the above hospital(s) to release medical, mental, alcohol and/or drug abuse, HIV (human immunodeficiency virus) testing, AIDS, eating disorders or any other medical information of a sensitive nature to the following individuals or organization(s):

Name:____________________________________________________________________________________

Address:__________________________________________________________________________________

(City)

(State)

(Zip)

•This information for which I’m authorizing disclosure will be used for the following purpose: Description:_______________________________________________________________________________

Dates of service to be released:________________________________________________________________

The type of information to be used or disclosed is as follows (check the appropriate boxes and include other information

where indicated). Copy medical records to	Electronic medium or	Paper
Abstract	Progress Notes
Discharge Summary	Lab results / X-Ray and Imaging
History and Physical Reports	Emergency Room Reports
Operative Reports	Consultation Reports

Other: (please describe)_______________________________________________________________

I understand that if the organization authorized to receive the information is not a health plan or healthcare provider, the release information may no longer be protected by Federal privacy regulations. I understand that I need not sign this authorization to ensure treatment. This authorization shall remain valid for six months from the date signed below.

I understand that I have a right to revoke this authorization at any time. I understand that if I revoke this authorization, I must do so in writing and present my written revocation to the department or facility listed on the authorization. I understand that the revocation will not apply to information that has already been released in response to this authorization. I understand that 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.

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