Form L2549 Ian – Fill Out and Use This PDF

DT0013

AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH

INFORMATION (PHI)

	RETURN TO:								Athens Regional Health Services, Inc.
								d/b/a Athens Regional Health System (“ARHS”)
										1199 Prince Avenue
										Athens, Georgia 30606
					PATIENT INFORMATION:
			Name				Date of Birth			Social Security Number
			Street Address							City, State, Zip Code

Medical Record Number

Patient’s Account Number

IHEREBY AUTHORIZE ARHS TO: (Check one below)

_________ RELEASE INFORMATION TO:

_________ OBTAIN INFORMATION FROM:

(Attorney/Physician/Institution/Agency/Individual)

	(Street Address)			(City, State, Zip Code)
	(Telephone Number)			(Fax Number)
	(Date(s) of Treatment)
	PLEASE INDICATE DELIVERY METHOD:	____ Will Pick Up ____ Mail to Address Above

FOR THE PURPOSE OF: _____ Healthcare Facility _____ Insurance _____ Legal _____ Permanent Release

_____ Personal _____ Physician _____ Disability _____ Pre-Surgical Evaluation

_____ Other (Please specify):

L2549-IAN (10/12)

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DT0013

Unless indicated by speciic request checked below, I permit the release of any and all information including, if any, information concerning drug/alcohol abuse records, venereal disease and other statutorily protected diseases, psychiatric records (excluding psychotherapy notes), or AIDS/HIV testing treatment records.

Please Check Speciic Information Requested for Release:

_____ All PHI in medical record	_____ ER Report(s)	_____ Discharge Summary
_____ Operative Report	_____ History and Physical	_____ Pathology Report(s)
_____ Progress/Ofice Note(s)	_____ Laboratory Report(s)	_____ Radiology Report(s)
_____ Other (Please Specify)_____________________________		_____ Images
_____ *Psychotherapy Note(s)		_____ Cardiac Records

*PATIENT INITIALS: __________*If this is a request for psychotherapy notes, I authorize these

records to be released along with the other requested information.

I understand that:

•I may revoke this authorization at any time in writing and present my written revocation to the ARHS facility.

•The revocation will not apply to information that has already been released in response to this authorization or to my insurance company when the law provides my insurer with the right to contest a claim under my policy.

•I may refuse to sign this authorization.

•Disclosure of health information is voluntary.

•I need not sign this authorization to ensure treatment nor will it affect my payment status.

•Any disclosure of information carries with it the potential for an unauthorized redisclosure.

•I may inspect or have a copy of the information described on this form if I ask for it.

•I get a copy of this form after I sign it.

Unless otherwise revoked, this authorization will expire on the following date, event or condition:

_____________________________________. If I fail to specify an expiration date, event or condition, this

authorization will expire in ninety (90) days.

AUTHORIZATION IS VALID FOR 90 DAYS FROM THE DATE OF SIGNATURE.

If I have questions about the disclosure of my protected health information, I can contact the Health Information Management Department or the Compliance Department. I have read the above and authorize the disclosure of the protected health information as stated.

_________________________________________	_______________________________
(Signature of Patient or Legal Representative)	(Date/Time of Signature)

If signed by legal representative, relationship of individual to patient: _____________________________

_________________________________________		_______________________________
(Signature of Witness)			(Date/Time of Signature)
_________________________________	_____________________		___________________________
(Witness Street Address)	(Witness Phone Number)		(City, State, Zip Code)

L2549-IAN (10/12)

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