kameronhealth.com - Release of Health Info

Patient Name

PrefixFirst NameMiddle NameLast NameSuffix

Date of Birth

Date

The above named person must indicate when this authorization is to expire.

Expiration

Date

The person named above is or has been a patient of:

Name of Person, Provider, or Facility

Provider Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Provider Phone

Area CodePhone Number

Provider Fax

Area CodePhone Number

The person named above hereby authorizes Kameron Health PLLC to:

The person named above authorizes information to be requested or released by representatives of:

Name of Person, Provider, or Facility

Address of Provider

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Provider Phone

Area CodePhone Number

Provider Fax

Area CodePhone Number

What kind and how much information to share:

Please specify details and/or dates of scope

Patient Name

First NameLast Name

Signature Date

Date

Signature

Witness Date

Date

Witness Signature

If not signed by the patient, indicate relationship of authorizing person to patient

If other relationship, please explain

Certain information is covered by additional protection and requires specific authorization. To authorize release or discussion of the following type of information, the person named above must initial and date each item. If an item is not initialed and dated, the information, if such information exists, cannot be released or discussed.

Initials

Authorization Date

Date

Treatment start date

Date

Treatment end date

Date

Initials

Authorization Date

Date

Treatment start date

Date

Treatment end date

Date

Initials

Authorization date

Date

Treatment start date

Date

Treatment end date

Date

The above named person has the following rights:

This authorization is effective for the above requested and authorized health care information only. You may ask for and receive a copy of this authorization form.
This authorization will expire on the date you indicated above. Additionally you may revoke this authorization at any time by submitting a written request to this clinic or caretaker. Your revokation will be honored except to the extent that is been acted upon in good faith while in force.
You have the right to inspect the information you are authorizing to be re-released. This and other specific rights regarding the handling of your health information are outlined in our Privacy Practices document.
The information you are authorizing to be released could be re-released or disclosed by the recipient. Such additional disclosures or releases may not be prohibited by law. We are not responsible for the actions of others who may be provided with information released as a result of this authorization.
You may refuse to sign this authorization. Such refusal will not affect your ability to obtain treatment except to the extent that the information being requested may assist your health care provider in determining appropriate treatment. Your refusal to sign this authorization will not affect your eligibilty for benefits.

PLEASE NOTE: Unless otherwise specified by law, we will release only that information which has been created by our employees or agents, including chart notes, lab results, summaries, and consultation reports. Records created by and available from other providers, hospitals, or other care facilities must be obtained directly from those other providers or facilities.

There may be a fee associated with the copying of your records. If for personal use, you are entitled to one copy of your personal health information record free of charge. Additional copies for you, future releases to you, or releases to other providers, persons or facilities may be subject to a reasonable charge. Please contact a clinic office manager or site administrator for additional information about applicable copying fees.

Authorization for Release of Health Informaiton

Scope

Authorization

Alcohol or drug use/abuse treatment

Mental Health Treatment

HIV status or treatment