Release of Information

Authorization to Use or Disclose Protected Health Information

Patient Name

First Last

Date of Birth

Date

I hereby freely and voluntarily authorize Wellstone Regional Hospital to release/disclose my protected health information to and/or obtain my protected health information from:

Individual, Facility, or Organization

Phone

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Fax Number

The purpose of this disclosure is for:

Insurance purposes
Discharge planning
Educational placement
Continued treatment
Legal reasons
The patient
Medical treatment
Progress updates
Other (explain below)

Information to be used or disclosed:

Level of Care Recommendation

I understand that my medical records may contain information regarding testing, drug, and/or alcohol diagnosis and treatment, a communicable or venereal disease which may include, but is not limited to, disease such as hepatitis, syphilis, gonorrhea, or the human immunodeficiency virus, also known as acquired immune deficiency syndrome (AIDS) and/ or tuberculosis. I understand that such information is confidential and is protected by federal law*. I understand that provision of health care treatment to me cannot be conditioned upon my agreement to sign an authorization for the disclosure or use of my health information for purposes other than for treatment, payment and healthcare operations. I understand that the potential exists for health information that is released with my authorization to be re-disclosed by the recipient, and to be no longer protected by the Federal HIPAA law. I understand that I have the right to revoke this authorization at any time by giving written notice to Well- stone Regional Hospital Privacy Officer, except to the extent that action has already been taken in reliance on it. This authorization will expire in 180 days, following discharge, or following signature unless another date or condition is specified.

Other date or condition specified:

Signature

(Patient/Resident-When applicable by law or hospital policy)

Date

Signature

(Patient/Resident-When applicable by law or hospital policy)

Date

(Relationship to Patient/Resident)

Signature

(Witness)

Date