Medical Records Authorization Authorization for Use and Disclosure of Protected Health Information **Form must be completed in its entirety prior to the release of Protected Health Information (PHI) ** Patient's First Name(Required) Patient's Last Name(Required) Phone Number(Required) Date of Birth(Required) MM slash DD slash YYYY Email(Required) Beginning date of care(Required) MM slash DD slash YYYY Include medical records beginning with this date.End date of care(Required) MM slash DD slash YYYY Conclude medical records ending with this date.Entity to whom the information is being released:(Required) For the purpose(s) of :(Required)Specify the reason that this information is being released.Protected Health Information(Required)Identify specific information to be released.Authorization(Required) I authorize the release of my medical records to the entity named above.1. I understand that I may inspect or obtain a copy of the protected health information described by this authorization. The fee for reproducing records, as allowed by state regulation, consists of a retrieval fee of $15.00 and $.25 per page. 2. I understand that the Surgery Center of Rhode Island will not condition treatment, payment or (if applicable) enrollment in the health plan or eligibility for benefits on my providing authorization for the requested use or disclosure AND THAT I MAY REFUSE TO SIGN THIS AUTHORIZATION. 3. I understand that I may revoke this authorization in writing at any time by delivering such written revocation to the Privacy Officer of The Surgery Center of Rhode Island. I also understand that such revocation will not be effective as to the disclosure of records whose release I have previously authorized, or where other action has been taken in reliance on an authorization I have signed. 4. I understand that information used or disclosed pursuant to this authorization could be subject to re-disclosure by the recipient and, if so, may not be subject to federal or state law protecting its confidentiality. EXPIRATION DATE: This authorization will expire on __ /__ / __ (date no longer than one year from now) (If no date is stated, this authorization will expire six months from the date it was signed.) COPY PROVIDED: The Surgery Center of Rhode Island shall provide a copy of this signed authorization to you upon your request. This information will be disclosed to you from records whose confidentiality is protected by federal law. Federal regulations prohibit you from making any further disclosure of it without the specific written consent of the person to whom it pertains. State law requires an individual or the individual’s authorized legal representative to give specific consent for the release of protected health information related to certain disease conditions. By my signature below, I authorize release of the following medical information that may be held by The Surgery Center of Rhode Island: general protected health information, information pertaining to my HIV status and records of care for HIV/AIDS, records of mental health care and treatment, records of substance abuse care and treatment and records or diagnosis, care and treatment of sexually transmitted disease. Untitled Untitled
