Request for Protected Health Information Policy #5510-F
This form should be used when release of a patient’s protected health information is being made to the health care provider for an
employee or student for a purpose other than treatment, payment or health care operations.
I, ____________________________________, hereby authorize _________________________
Name of Employee, Student 18 or older, or Parent/Guardian Name of Physician/Practice
to use and/or disclose my protected health information described below to ________________________.
My protected health information will be used or disclosed upon request for the following purposes (name and explain each purpose): __________________________________________
This authorization for use and/or disclosure applies to the following information (please mark those that apply):
o Any and all records in the possession of the above-named physician or physician’s practice, including mental health, HIV, and/or substance abuse records. (Please cross out any item you do not authorize to be released.)
o Records regarding treatment for the following condition or injury ____________________________ on or about_______________________.
o Records covering the period of time _____________________ to ________________.
o Other (Specify and include dates.)______________________________________________.
I understand that I have the right to revoke this authorization, in writing, at any time by sending such written notification to above-named physician/practice. I also understand that my revocation is not effective to the extent that the persons I have authorized to use and/or disclose my protected health information have acted in reliance upon this authorization.
I understand that I do not have to sign this authorization and that the above-named physician/practice may not condition treatment or payment on whether I sign this authorization.
I understand that information used or disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and no longer protected by federal laws and regulations regarding the privacy of my protected health information.
This authorization expires on the following date or event: _______________________________.
I certify that I have received a copy of this authorization.
Signature of Patient or Personal Representative Date
Name of Patient or Personal Representative Personal Representative's Authority