Authorization for Use and Disclosure of Protected Health Information

I hereby authorize _____________________________to release the Medical Record of
Printed Name: ________________________________ Date Of Birth: _______________________
Address: ____________________________________ SSN#: _____________________________
 ___________________________________________ Telephone #: ________________________
Information To Be Released - Covering the Periods of Health Care
From (date) __________________________ To (date) __________________________
Please check type of information to be released:
___ Entire medical record ___ Pathology report ___ Discharge summary
___ History and physical exam ___ Consultation reports ___ Progress notes
___ Lab test results/reports  ___ X-ray reports ___ X-ray films/images
___ Operative reports ___ Emergency room record ___ Itemized bill
___ Other (specify) _______________________________________________________________
Purpose of Request  
____ Treatment or consultation ____  At the request of the patient ____ Billing or claims payment
____ Other (specify) _______________________________________________________________
Person Authorized to Receive Information  
Name: ________________________________  
Address: ________________________________________________________________
THE INFORMATION AUTHORIZED FOR RELEASE WILL IDENTIFY THE PATIENT AND MAY INCLUDE INFORMATION WHICH COULD BE CONSIDERED A COMMUNICABLE OR VENEREAL DISEASE  THIS MAY INCLUDE BUT IS NOT LIMITED TO DISEASES SUCH AS HEPATITIS, SYPHILIS, GONORRHEA, AND THE HUMAN IMMUNODEFICIENCY VIRUS. ALSO KNOWN AS ACQUIRED IMMUNE DEFICIENCY SYNDROME (AIDS)
Drug and/or Alcohol Abuse, and/or Psychiatric, and/or HIV/AIDS Records Release
I understand that is my medical or billing record contains information in reference to drug and/or alcohol abuse, psychiatric care, sexually transmitted disease, Hepatitis B or C testing, and/or other sensitive information. I agree to its release.

                                                                                                                 Check one: ___Yes ___No _________ Initials
I understand that if my medical or billing record contains information in reference to HIV/AIDS (Human immunodeficiency Virus/      Acquired Immunodeficiency Syndrome) testing and/or treatment. I agree to its release.

                                                                                                                 Check one: ___Yes___ No _________ Initials
Time Limit & Right to revoke Authorization  
Except to the extent that action has already been taken in reliance on this authorization, at any time I can revoke this authorization by  submitting a notice in writing to the facility Privacy Officer at 525 East Blue Star Drive, Claremore, OK 74017 Unless revoked, this authorization will expire on the following date or event: ___________________________________________________
Re-disclosure  
I understand the information disclosed by this authorization may be subject to re-disclosure by the recipient and will no longer be protected by the Health Insurance Portability and Accountability Act of 1996. The facility, its employees, officers and physicians are hereby released from   any legal responsibility or liability for disclosure of the above information to the extent indicated and authorized herein.
Signature of Patient or Personal Representative Who May Request Disclosure
I understand that Youth Care may not condition my treatment on whether I sign this authorization form unless specified above under Purpose of Request. I can inspect or copy the protected health information specified above.
Signature: ________________________________  Date:____________
Authority to Sign if not patient: ____________________
Identity of Requestor Verified via: ___ Photo ID ___  Matching Signature ___ Other Specify _______________________________
Verified by: ______________________________________________________________________