6550 East Second Street, Casper, WY82609

Telephone #307-995-8100 / Fax# 307-234-9472

AUTHORIZATION FOR DISCLOSURE / RELEASE OF MEDICAL INFORMATION

Please complete all fields with bold heading.

Patient Legal Name:______

(Last) (First) (MI)

Address:______City ______State ______Zip______

Date of Birth ______/______/______Age ______Telephone ______

I hereby authorize, ______

(Name of Facility Releasing Records)

to disclose and release my protected health care information, as defined in the Health Insurance Portability and Accountability Act of 1996 ("HIPAA"), including billing, payment, insurance and medical record information to, and for the purpose of:

□Self □Physician □Other (Specify)______

□Insurance Company □Continuing Care □Legal

Please specify date(s) of service: ______

Please specify location of records: □Hospital □Clinic □Both

Please release these records to:Name______

Address: ______

City______State ______Zip ______

Telephone #______Fax#______

______

Your initials below allow the designated facility to disclose information protected under law relative to drug and alcohol treatment, and psychiatric care, or diagnosis or information specified to HIV, AIDS.

I understand this will include information related to: (initial if applicable, must be initialed for disclosure of this information).

(Initials) ______Aids or HIV (Initial) ______Treatment for Alcohol/Drug Abuse

(Initials) ______Psychiatric Mental Health Information

For the purpose of review/examination/continuing care, and further authorize ______

(Name of Facility Releasing Records)

to provide such copies thereof as may be requested. The foregoing is subject to such limitation as indicated below:

Entire Record ______Specific Information______

This authorization will automatically expire one year from the date signed. I understand that I may revoke this consent at any time except to the extent that action has been taken in reliance thereon.

I understand that information that is disclosed under this authorization may no longer be protected after it is disclosed and that it is not possible for the hospital, physician or provider that release information under this authorization to ensure the privacy of any disclosed information after it is disclosed or that the information is used by the recipient identified above solely for the intended purpose.

NOTICE: Any information released pursuant to this authorization is confidential and protected by state and federal law. Further disclosure is prohibited unless expressly authorized in writing by the person to whom it pertains or otherwise permitted by law. Federal law restricts any use of the information to criminally investigate or prosecute any alcohol or drug abuse patient.

Signed______Date ______

Witness______Date ______

*ROI*

ROI (MVRH-129)

Approved: November 2017

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