Authorization for Release of Medical Information (Phi)

Shady Grove Fertility

9600 Blackwell Rd., Suite 500,Rockville, Maryland 20850

Phone: 301-545-1417 Fax: 301-545-1416

Email:

Facility # 44990

AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION (PHI)

______

(Print patients full name) Date of Birth (Mo/Day/Yr)

______

(Street Address)Social Security Number

______

(City, State, Zip Code) Phone (Daytime)

At the request of the individual, I ______, do hereby authorizeShady Grove Fertility

(Patient Name)

to releaserecords for the time period dating from______to ______:

______HISTORY & PHYSICAL ______ULTRASOUND REPORTS ______STIM GRIDS

______PROGRESS NOTES ______LABORATORY REPORTS ______EMBRYOLOGY REPORTS

______CONSULTATION NOTES ______RADIOLOGY REPORTS ______ENTIRE MEDICAL RECORD (includes all above)

______OPERATIVE REPORTS ______PATHOLOGY REPORTS OTHER______

_____ I DO____ I DO NOTauthorize release of HIPAA protected information related to AIDS or

(PLEASE INITIAL ONE ABOVE)HIV infection, sexually transmitted diseases, genetic testing, psychiatriccare and/or psychological assessment, and treatment for alcohol and/or drugabuse.

INFORMATION RELEASE TO:______

**Records can only be mailed to NAME of Company/Agent/Facility/Person

Physician’s office, not emailed. ______

If a patient email address is provided Street Address

the records will SOLELY be sent ______

via email. City, State, ZipCode

______

(Phone Number)

EMAIL DELIVERY: (PROVIDE EMAIL ADDRESSONLYIF SELF/PATIENT IS RECIPIENT):

______

PURPOSE OF DISCLOSURE:______

I hereby authorize disclosure of the health information for the above named patient. This authorization is valid for 12 months from the date of signature. I understand that I may cancel this request with written notification but that it will not affect any information released prior to notification of cancellation.CIOX Health will not maintain the images beyond 30 days-subject to additional fees. I understand that the information used or disclosed may no longer be protected by federal privacy laws. I further understand that this authorization is voluntary and that I may refuse to sign this authorization. My refusal to sign will not affect my ability to obtain treatment; or eligibility for benefits unless allowed by law. By signing below I represent and warrant that I have authority to sign this document and authorized the use or disclosure of protected health information.

______(By signing this form you are agreeing to the fee below) ______/______/______

Signature of individual or guardian or Personal Representative of patient’s estate Date

Please provide current telephone number in the event we need to contact you: ______

May we leave a message at the telephone number provided: Yes_____ No______

NOTE: THERE IS A CHARGEOF $6.50 FLAT FEE + TAX FOR ALL RECORDS DELIVERED ELECTRONICALLY OR $0.12 CENTS PER PAGE + $0.90 PROCESSING FEE + TAX + POSTAGEFOR RECORDS DELIVERED VIA MAIL. CIOX HEALTH HAS BEEN CONTRACTED TO PROVIDE THIS SERVICE AND WILL INVOICE YOU DIRECTLY.

For Billing or Customer Service Inquiries: CIOX Health 1-800-236-3355

For Records Request Receipt Confirmation or Status: SGF Medical Records 301-545-1417

Sept. 2016-MDD