Friends and Family - Columbus Arthritis Center

Limited Patient Authorization for Disclosure of Protected Health Information

Authorization to release information to friends/family

Please print all information. Form must be signed and dated.

First Name*

Last Name*

SSN (last four digits)*

Date of Birth*

Purpose of request (who will be authorized to receive information) - I authorize the entity identified above to disclose or provide protected health information, about me to the individual/entity listed below.

Who will be authorized to receive information (the individual/entity who is to receive your PHI):

Individual/Entity Name*

Address*

Street Address Address Line 2 City State ZIP Code

Email

Phone

Fax

Description of information to be disclosed

I authorize the practice to disclose the following protected health information about me to the entity, person, or persons identified above (Please select "Entire patient record" or check only those items of the record to be disclosed):

Entire patient record

Description of information to be disclosed

Office notes
Lab results, pathology reports
X-rays
Financial history report (previous 3 years only).
Nursing home, home health, hospice, and other physician records
Record of HIV and communicable disease testing
Record of mental health or substance abuse treatment
Other

Only send the following

Purpose of disclosure

Please record the purpose of the disclosure or check patient request

Patient Request
Other

Purpose of disclosure - Other

Authorization Expiration

This authorization will expire at the end of the calendar year, unless you specify an earlier termination. You must submit a new authorization form after the expiration date to continue the authorization. Please list the date of expiration if earlier than the end of the calendar year.

You have the right to terminate this authorization at any time by submitting a written request to our Privacy Manager. Termination of this authorization will be effective upon written notice, except where a disclosure has already been made based on prior authorization.
The practice places no condition to sign this authorization on the delivery of healthcare or treatment.
We have no control over the person(s) you have listed to receive your protected health information. Therefore, your protected health information disclosed under this authorization may no longer be protected by the requirements of the Privacy Rule, and will no longer be the responsibility of the practice.

Signature*

To sign, please preface your signature with "/s/" to confirm you're signing electronically.

Date*