Authorization To Release Health Information

Name*
First Last
Date of Birth*
Day Phone #*
I Authorize Fort Norfolk Medical to Release my health information
- Yes
To Release the Following Information:*
- Operative Report
- Entire Record
- X-rays or Imaging Report
- Discharge Summary
- Laboratory Results
- Immunization Record
- Other
Person/Facility to Receive Information:
Mailing Address:
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Release Format*
- US Mail
- Electronic format: CD/DVD
- Radiology Film/CD
- e Delivery by Healthport
Email*
Purpose of Release:*
- Physician
- Insurance
- Legal
- Disability Determination
- Personal
- Worker’s Compensation
- Other
Other Purpose of Release*
Authorization to Release Information:
1. I understand that I am giving my permission to release confidential health care records, unless indicated below, relating to, if applicable, sexually transmitted disease, Acquired Immunodeficiency Syndrome (AIDS), or Human Immunodeficiency Virus (HIV). It may also include information about behavioral or mental health services and treatment for alcohol and drug abuse. Special Instructions:
2. I understand that authorizing the release of this health information is voluntary. I can refuse to sign this authorization. I need not sign this form in order to ensure treatment. I understand that I may inspect or copy the information to be used or released, as provided in CFR 164.524. I understand that any release of information carries with it the potential for an unauthorized re-disclosure and the information may not be protected by federal confidentiality rules. If I have questions about the release of my health information, I can contact the organization above releasing the information.

3. I understand that I have the right to revoke this authorization at any time. I understand that in order to revoke this authorization, I must do so in writing and present my written revocation to the organization. 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. Unless otherwise revoked, this authorization will expire 6 months from the date of signature.

4. I understand that I will be given a copy of this authorization form, after signing. I understand that copying charges will be applied, according to the organization’s policy.
Signature of Patient or Legal Representative*

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Authorization to Release Information: