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Release of Information

Release of Information

FROM:

TO:

Facility Address
Facility Address
Address 1
Address 2
City
State/Province
Zip/Postal
Information to be released
Purpose of Release
Method of disclosure
By my signature below, I understand and consent to the following:
  • My health information is protected by federal (HIPAA 45 CFR, 42 CFR Part 2) and state laws and regulations, and disclosure is allowed only with my authorization, except in limited circumstances described in the facility’s Notice of Privacy Practices.
  • The facility releasing the information cannot control how the recipient uses or shares the information, and cannot prevent further release by the recipient.
  • I understand releases pursuant to this authorization will identify me as receiving services at this facility.
  • My consent is voluntary and I may revoke this authorization at any time by giving written notice to the facility, except to the extent that action has already been taken in reliance upon it.
  • I allow EOSIS owned or affiliated programs to continue to use this release upon transfer of my care to them.
  • Unless revoked earlier or otherwise indicated, this authorization will expire one (1) year from the date of signing.
  • The facility may charge a per page copy fee.
  • A fax of photocopy that has not been altered may be considered as valid as the original.
Patient or Patient Representative: Please make sure all appropriate sections above are completed. Do not sign a blank authorization form.
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