REQUEST FOR RELEASE OF INFORMATION
Mobile Infirmary | P 251-435-2286/ F 251-435-5884
Infirmary LTAC | P 251-435-1206/ F 251-435-5884
Thomas Hospital | P 251-279-1570/ F 251-279-1490
North Baldwin Infirmary | P 251-580-1754/ F 251-937-7305
Name
Date of Birth
Address
Phone Number/ Fax Number
City, State, Zip Code
Social Security Number (last 4 digits)
I hereby authorize:
Mobile Infirmary
Infirmary LTAC
Thomas Hospital
North Baldwin Infirmary
Other:
to release to
Name and Address
This consent and authorization may include, but is not limited to, the release of medical, psychological, psychiatric, alcohol, drug abuse, STD and HIV/AIDS information.
Purpose of Disclosure:
The specific information to be released is:
Abstract (pertinent physician documentation and results)
ED Record
Progress Notes
Facesheet
X-ray Reports
Nurses' Notes
Entire Record
X-Ray Images/CDs
Lab Reports
History and Physical
Pathology Reports
Itemized Statements
Discharge Summary
Consultation Reports
UB-04
Operative Report
Physicians' Orders
Other:
Dates of Hospitalization or Visit:
Medium to be used:
Paper
MyIHChart
CD/DVD
Email Address
I understand that this consent is revocable, except to the extent that action has already been taken in reliance thereon. Request for revocation of this authorization must be in writing. This authorization will expire (i) after 1 year, (ii) after the disclosure is made, or (iii) the date specified here:
, to accomplish the purpose of the disclosure stated above.
Electronic Signature of Patient or Representative Date/Time
Relationship (if other than patient)
Electronic Signature of Witness Date/Time
Information used or disclosed pursuant to this authorization may be subject to redisclosure by the recipient and is no longer protected under Title 45, CFR. Infirmary Health may not condition treatment or payment on whether you sign this authorization, unless this authorization is for the provision of research-related treatment or for the creation of health information for disclosure to a third party.