Authorization Form For Release Of Information

TO:  ___________________________________

___________________________________

___________________________________

___________________________________

 

Patient Name:  _____________________ Date of Birth:  _______________       SSN:  ________________

Address:

I authorize the disclosure of all protected medical information for the purpose of workers’ compensation proceedings. I expressly request that all health plans and all health care providers identified above disclose full and complete protected medical information spanning the time period of __________________ to present and continuing, including the following:

• All medical records, including inpatient, outpatient and emergency room treatment, all clinical charts, reports, documents, correspondence, test results, statements, questionnaires/histories, office and doctor’s handwritten notes, and records received by other physicians.
• All autopsy, laboratory, histology, cytology, pathology, radiology, CT scan, MRI, echocardiogram and cardiac catheterization reports.
• All radiology films, mammograms, myelograms, CT scans, photographs, bone scans, pathology/cytology/histology/autopsy/immunohistochemistry specimens, cardiac catheterization videos/CDS/films/reels, and echocardiogram videos.
• All pharmacy/prescription records including NDC numbers and drug information handouts/monographs.
• All billing records including all statements, itemized bills and insurance records.

Unless you initial here, no information about alcohol/substance abuse, psychiatric/psychological treatment of HIV/AIDS will be disclosed.

___ Yes, disclose HIV/AIDS information.                                    ____ No, do NOT disclose HIV/AIDS information.

___ Yes, disclose alcohol/substance abuse information.       ____ No, do NOT disclose alcohol/substance abuse

information.

___ Yes, disclose psychiatric/psychological information.    ____ No, do NOT disclose psychiatric/psychological information.

I authorize you to release the protected health information to: Calhoon and Kaminsky P.C., 2411 North Front Street, Harrisburg, PA  17110

I acknowledge the right to revoke this authorization by writing to Calhoon and Kaminsky P.C., at the above-referenced address. However, I understand that any actions already taken in reliance on this authorization cannot be reversed, and my revocation will not affect those actions. I acknowledge the potential for information disclosed pursuant to this authorization be subject to redisclosure by the recipient and no longer by protected by 45 CFR 164.508. I acknowledge the right to inspect the material to be released. I understand that the covered entity to whom this authorization is directed may not condition treatment, payment, enrollment, or eligibility benefits on whether or not I sign the authorization. Any facsimile, copy or photocopy of this authorization shall authorize you to release the records herein.

This authorization expires two years from the date below:

Signature:  _____________________________________     Date:  ______________________________

Relationship to the person who is the subject of the records:

Self:  ________                   Other:  __________________________________________________________