(Name of Provider) to release information from my medical record a

Authorization for Release of Information to AHP
1. I understand that this authorization will expire on _______________
(Print the Date you would like this Form to expire, allowing at least 30
days for us to gather, copy, and send your information. If blank,
authorization will expire one (1) year from date of signature.)
2. I understand that I may cancel this authorization at any time. To cancel
this authorization, I must notify Arch Health Partners in writing. This
authorization will be cancelled once Arch Health Partners has received
my written notice to cancel. The exception to this would be if my
information has already been released.
3. I understand that if I am being requested to release this information by
__________________ (Print Name of Provider) for the purpose of
_______________________________________.
a. I understand I may see and copy the information described on this
form if I ask for it, and that I will get a copy of this form after I sign it.
b. I have been informed that Arch Health Partners will not receive
financial or in-kind compensation in exchange for using or disclosing
my health information as described above.
c. I understand that treatment, payment, continued enrollment in a
health plan or eligibility for benefits will not be conditioned upon my
authorization.
4. I understand that in compliance with California statute, I will pay a fee of
$______________ (Print the Fee Charged). There is no charge for
medical records if copies are sent to facilities or providers for ongoing
medical care or follow up treatment.
___________________________________________________________________________________
Signature of Patient
Date
____________________________________________________________________________________
Signature of Parent/Legal Guardian/Authorized Person
Date
____________________________________________________________________________________
Records Received By Date Relationship to Patient
FOR OFFICE USE ONLY
DATE REQUEST FILLED: ________________________________ BY: _________________________________________
IDENTIFICATION PRESENTED: __________________________ FEE COLLECTED: $_________________
REQUEST FOR RECORDS DENIED LETTER SENT TO PATIENT BY: _________________________
SECOND-LEVEL REVIEW APPROVED
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PP933B/Autho for Release form US/4/08/bc