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FROM: Patient Name______________________________ Birthdate__________ SSN____________________
Address______________________________ City____________________ State_____ ZIP__________
TO: Medical Records Department
Hospital Name_________________________ Fax____________________ Tel.____________________
Address______________________________ City____________________ State_____ ZIP__________
You are hereby authorized to release to Dr. Taylor my operative report for the tubal ligation performed on me on __________(date) at your hospital.
I understand I have a right to refuse to sign this Authorization, and to inspect and copy the health information to be released. If I do not sign this Authorization, the hospital named above will not release my health information. The Healthcare for Women will not refuse to treat me based on whether I agree to allow my health information to be used and disclosed to others.
I understand that I may revoke this Authorization at any time by giving written notice to the Hospital and Healthcare for Women, but that this revocation will not be valid if action has already been taken to release my health information based on this Authorization, or if this Authorization is granted to obtain insurance coverage, which is covered under other law.
I understand that the health information covered by the Authorization may be re-disclosed and no longer protected by Federal privacy rule.
This Authorization is valid for one (1) year from the date signed unless limited by the following event, condition, or date: ____________________________________________________________
Patient Signature______________________________ Date____________________
Or, Patient’s Parent/Guardian/Legal Representative________________________________________
Date____________________ Relationship to Patient________________________________________
Witness Signature______________________________ Date____________________ |
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Patient Medical Records/Health Information Release Authorization
Lyndon D. Taylor, MD 1100 Lake Street, Suite 260 • Oak Park, Illinois 60301 Telephone # (708) 848-9440 • Facsimile # (708) 848-4415 |
