KEYSTONE HEALTH
AUTHORIZATION FOR RELEASE OF MEDICAL/DENTAL RECORD INFORMATION
I hereby authorize the release of my health information as listed below.
Patient name: ______DOB: ______Gender □M □F
Address: ______Phone : ______
______
PROVIDER OR FACILITY AUTHORIZED TO RELEASE INFORMATION:
______
Address: ______Phone: ______
______Fax: ______
PERSON OR ENTITY AUTHORIZED TO RECEIVE INFORMATION:
______
Address: ______Phone: ______
______Fax: ______
Description of information: □Electronic Health Record(one copy at no charge)
□Paper Record (Fee charged)
□DentalRecord (may be charged a fee for x-ray copies)
□Specific Dates of Service______
MedicalCopy includes: office notes, lab and testing results, hospital reports, consult notes, immunization reports, medication list, allergies and chronic conditions. This includes the same information on any Past Medical Records we have on file in the Electronic Record.
All record requests may include information from Family Medicine, Keystone Audiology and Speech, Internal Medicine, Women’s Care, Keystone Pediatrics, HIV, Behavioral Health, Crisis and Urgent Care
*SPECIAL RECORDS: Medical records to be released may includerecords of drug and alcohol abuse program treatment, mental health treatment, confidential HIV-related information or sexual abuse/assault counseling records unless the specific boxes below are checkedindicating to exclude this information. Indicating an exclusion reduces the amount of information that can be released and potentially places you at risk..
□ drug /alcohol treatment records □ confidential HIV records □mental health records □Sexual abuse/assault counseling records/
Checking the box is not a representation that such information exists. and Reproductive rights
Purpose of Release of Information:
□Personal Use □Continuing Care □Unhappy with care □Moving □Insurance Related
□Transferring out of practice □Transferring into practice□Legal Reasons
- This authorization will expire : □ Date ______□ Event ______□ One Year
Unless otherwise specified, this authorization will expire 90 days after the date of this request.
- I understand that I may revoke this authorization at any time by notifying the Facility’s Privacy Officer in writing of
my revocation. I understand that revocation will not have any affect on actions the Practice took before they received the
revocation.
- This authorization is voluntary. I understand that my treatment or payment for services will not be affected if I do not sign this authorization.
- I understand that if the organization authorized to receive the information is not a health plan or a health care provider,
the information may no longer be protected by federal privacy regulations.
- I understand once I take possession of the requested copy, it is then my responsibility to safeguard the Protected Health Information.
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Signature of patient or patient’s representativeDate
Printed name of patient’s representative: ______Relationship to patient: ______
Request reviewed with patient or representative by______Date______
Revised 4.15 PSG MR #______Staff initials______