Download the Medical Information Release Authorization form

MEDICAL INFORMATION RELEASE AUTHORIZATIONWho is releasinginformation The Medical Center250 Park StreetBowling Green, KY 42101 The Medical Center at Scottsville456 Burnley RoadScottsville, KY 42164 The Medical Center at Franklin1100 Brookhaven RoadFranklin, KY 42134 Commonwealth RegionalSpecialty Hospital250 Park StreetBowling Green, KY 42101 The Heart Institute350 Park Street, Suite 210Bowling Green, KY 42101 Neuroscience Services825 Second Avenue, Ste. B2Bowling Green, KY 42101 Surgical Weight Loss Program825 Second Avenue, Ste. A4Bowling Green, KY 42101 Urgentcare1225 Fairway Street, Ste. 100Bowling Green, KY 42103 Corpcare1110 Wilkinson TraceBowling Green, KY 42103 Quick Care Clinic2435 Nashville Road, Ste. 109Bowling Green, KY 42101 Bluegrass Outpatient Center/ Just for Women1110 Wilkinson TraceBowling Green, KY 42103 Women’s Health Specialists350 Park Street, Ste. 203Bowling Green, KY 42101 Psychiatric Associates of BG350 Park Street, Ste. 204Bowling Green, KY 42101 CHC Employee Health Services720 Second Avenue, Ste. 207Bowling Green, KY 42101 Walter R. Warren, M.D.825 Second Avenue, Ste. A3Bowling Green, KY 42101 ENT of Bowling Green340 New Towne DriveBowling Green, KY 42103 Rural Health Clinic466 Burnley RoadScottsville, KY 42164 Fountain RunRural Health Clinic47 Akersville RoadFountain Run, KY 42133 Barren River RegionalCancer Center103 Trista LaneGlasgow, KY 42141 ________________________________________________________________________________________________PatientIdentificationRelease records toDates of treatmentReason for releaseName:________________________________________________________________Date of Birth:___________________________SS#____________________________Name:_________________________________________________________________Address:_____________________________________________________________________________________________________Fax #:___________________________Dates:_________________________________________________________________Type of treatment: (may include psychiatric, drug or alcohol abuse)_____ ER _____ Outpatient _____ Inpatient_____ Medical Care _____ Insurance _____ Legal Claim_____ Other, Please explain:_____________________________________________________________________________________________________________________Information youwant released(Check what you want)_____ H & P_____ PATH_____ ENTIRE_____ DG SUMM_____ X-RAY_____ OR REPORT_____ ER REPORT_____ OUTPT_____ LAB (May include AIDS/HIV information)_____OTHER ____________________________________________________________________________________________________________________________________________________________________________________Account Number _____________________________________MEDICAL INFORMATIONRELEASE AUTHORIZATION600195 (230) Rev. 9/11

I understand that this authorization is valid only for a maximum of 90 days from the date below, and it coversonly treatment prior to the date below.This information may be released by facsimile machine if request warrants. Commonwealth HealthCorporation and its subsidiaries are hereby released from any liability and the undersigned will holdCommonwealth Health Corporation harmless for complying with this authorization. A photostat copy of thisauthorization is acceptable and will be treated as original.The undersigned acknowledges that the provision of free medical records by any healthcare provider whoreceives this release shall fulfill that healthcare provider’s obligation to provide one free copy of the medicalrecords, and that any future report request for medical records from the healthcare provider may result in acopying fee up to one dollar per page.I understand that the information in my health record may include information relating to sexually transmitteddisease, acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV). It may alsoinclude information about behavioral or mental health services, and treatment for alcohol and drug abuse.I understand that I have a right to revoke this authorization at anytime. I understand that if I revoke thisauthorization I must do so in writing and present my written revocation to the Health Information ManagementDepartment. I understand that the revocation will not apply to information that has already been released inresponse to this authorization. I understand that the revocation will not apply to my insurance company whenthe law provides my insurer with the right to contest a claim under my policy.Revocation date__________________ Patient/Legal Representative:______________________________I understand that authorizing the disclosure of this health information is voluntary. I can refuse to sign thisauthorization. I need not sign this form in order to assure treatment. I understand that I may inspect or copy theinformation to be used or disclosed, as provided in CFR 164.524. I understand that any disclosure ofinformation comes with it the potential for an unauthorized redisclosure and the information may not beprotected by federal confidentiality rules. If I have questions about disclosure of my health information, I cancontact the Health Information Management Department.Patient/Legal Representative Signature: ____________________________________ Date:_____________Relationship to patient:__________________________________Please mail the completed authorization form to:Attn: Release of InformationHealth Information Management DepartmentThe Medical Center250 Park StreetBowling Green, KY 42101FOR OFFICE USE ONLY Released by: ____________________________________ # of pages copied: ______________First free copy: Yes No MEDICAL INFORMATIONRELEASE AUTHORIZATIONPage 2 600195 (245) Rev. 9/11