Authorization Form - Providence Washington

From: Release of Information Department
IOD Correspondence Department
Providence Holy Family Hospital
RE:
Request for Copies of Medical Records
Thank you for your interest to obtain Medical Record Information.
To assist in your request an "Authorization for Release of Information" form is
attached. Please complete the form and return it, along with a copy of your driver's
license or other legal picture identification. When we have received this release and
verification of identity we will process you request promptly.
If you are signing on behalf of a patient for whom you are legal guardian or
personal representative, you must attach a copy of your appointment as legal
guardian or personal representative. If you are signing on behalf of a patient who is
deceased, you must attach a photocopy of the client’s death certificate.
Your may fax your request to our Correspondence Department at (509) 482-2198 to help
expedite processing. Please call us at (509) 482-1818 if you have any questions.
Ensuring the protection of confidentiality of patient records is our top priority. Thank you
for you patience and assistance.

AUTHORIZATION FORM
I _______________________________ hereby authorize to
Requester’s Name
Name of Hospital or Physician
___release and/or ____ receive information to/from Providence Holy Family Hospital, contained in
Patient’s Name
Medical Record, including alcohol and
drug abuse records protected under the regulation in Code 42 of Federal Regulations, Part 2, if any; psychological and
psychiatric records, if any; social services records, if any; records of Human Immunodeficiency Virus (HIV) testing including
results, if any; records of Acquired Immunodeficiency Syndrome (AIDS), ARC (AIDS related Complex), if any; and records of
communicable diseases, if any; to the individuals or organizations listed below, only under the conditions listed below:
NAME OF INDIVIDUAL/ORGANIZATION:
ADDRESS:
CITY/STATE/ZIP :
TELEPHONE NUMBER:
I. PATIENT IDENTIFICATION
Patient’s Date of
Birth:
Name Used at
Time of Treatment:
FAX NUMBER:
Social Security
Number:
Date(s) of
Treatment:
II. RECORDS TO BE RELEASED (Select all that apply)
Inpatient Medical Records Outpatient Treatment or Testing Emergency Medical Records
Entire Record Discharge Summary Operative Reports
ER Records Lab Report X-Ray Reports
Progress Notes Pathology Reports EKG Reports
History and Physical Consultation Reports Other, specify:
III. PURPOSE OF DISCLOSURE
THE INFORMATION BEING DISCLOSED IS FOR THE PURPOSE OF:
Personal Insurance Attorney Continuing Health Care Other: _________________________
IV. SIGNATURE
SIGNATURE:
DATE:
RELATIONSHIP TO PATIENT: IDENTIFICATION CHECK: YES NO Refused
V. RIGHTS OF THE PATIENT:
• The information listed here above is to be released for the stated purpose only. Any other use is forbidden.
• I may inspect and receive a copy (nominal fees may be charged) of the information to be used pursuant to this authorization.
• This authorization is voluntary and I may refuse to sign this form. I will not be refused treatment if I refuse to sign this form.
• This authorization is valid for a period of 90 days or until the date of: ____/____/____. I understand that I may also revoke
authorization at any time by contacting Health Information Management at Providence Holy Family Hospital.
My revocation must be in writing. However, the hospital is not responsible for actions already taken based upon this
authorization. I may not be able to revoke this authorization if its purpose was to obtain insurance.
• If I am providing authorization for marketing purposes, I understand that Holy Family Hospital may receive payment from
a business associate as a result of using or disclosing my information.
• I understand that information used or disclosed pursuant to this authorization may be subject to re-disclosure by the recipient
and may no longer be protected by federal and state law.

Providence Holy Family Hospital
5633 N. Lidgerwood St.
Spokane, WA 99208
(509) 482-2131
IOD Incorporated
27 W. Indiana Ave. Suite 110
Spokane, WA 99205
(509) 747-5700
Notice To Patients
Photocopy Charges For Medical Records
We will be happy to provide copies of your medical records per your request.
Holy Family contracts with IOD Incorporated, a professional medical record
copying service, to ensure that your copies are available to you as quickly
as possible.
Prior to copying your records, IOD Incorporated would like you to
know that there is a charge for this service, and prepayment is required.
1-9 pages = No charge
10-30 pages = $ .88 per page
31+ pages = $ .67 per page
Postage and tax (8.6%) will be charged when applicable.
The ability to charge for the copying of medical records, to cover the costs of
labor and supplies, has been developed by the Washington State Legislature and
is outlined in RCW 70.02.
IOD Incorporated will contact you with the prepayment amount. Medical Records
will not be copied until prepayment is received.
If you have any questions regarding the process of your request, please call
(509) 482-1818 or (877) 328-7344, ext. 72, Monday through . Friday, 7 a.m. to 4:30 p.m.
I understand that there is a charge to copy my medical records and that
IOD Incorporated requires prepayment. IOD Incorporated will notify me of the
charge and when they receive prepayment in full, my records will be copied.
Patient Signature ____________________________________
Date________
Address _________________________________________________
_________________________________________________
_________________________________________________
Phone Number ___________________________________________