Columbia County Health System
Dayton General Hospital Booker Adult Family Home Booker Rest Home Annex
Columbia Family Clinic Waitsburg Clinic
1012 South Third, Dayton, Washington 99328-1696
(509) 382-2531 Fax (509)382-3209
AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION
Patient’s Name:____________________________________________________ MR#____________________
Address:__________________________________________________________ Telephone #:_____________
Previous Name(s):__________________________________________________ Birth Date:_______________
Date Requested By: ___________________________ Upcoming Appointment ?_______ Yes ______ No
I Hereby Authorize:
______________________________________________________________________________
(Individual/Agency)
______________________________________________________________________________
(Address)
______________________________________________________________________________
(City, State, Zip Code)
To Provide Medical Information to:
___________________________________________________________
(Individual/Facility)
_______________________________________________________________________________
(Address)
_______________________________________________________________________________
(City, State, Zip Code)
Date(s) of treatment:___________________________________________________________________________________________
Data requested:
__________ Physician notes __________ Operative Reports
__________ Lab/Pathology Reports __________ History and Physical
__________ X-Rays __________ EKG
__________ Reports __________ All health care records
__________ Films __________ Other:___________________________
For the purpose of: _______________________________________________________________________________________
Permission to fax and/or send electronically __________ YES __________ NO
To be valid, this authorization must be dated within 90 days of the request for information. I may revoke this authorization in writing at any time, provided that the information has not yet been released. To view the process for revoking this authorization, please read the Privacy Notice to our patients. I understand that once Columbia County Health System discloses health information, the person or organization that receives it may re-disclose it, at which time it may no longer be protected under Privacy laws. I understand I do not have to sign this authorization in order to receive health care benefits.
__________________________________________ ________________________________________________
Patient Signature Date/Time Parent, Legal Guardian or Authorized Representative* Date/Time
{* Please provide documents to prove authority to sign on behalf of patient}
Witnessed _________________________________________
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By checking and signing below, I specifically authorize the release of the following confidential information: __________ HIV test and test results and related information __________ Sexually transmitted diseases __________ Drug/alcohol diagnosis, treatment or referral information __________ Psychiatric disorders/mental health
________________________________________ ________________________________________________________ Patient Signature Date/Time Parent, Guardian or Authorized Representative* Date/Time {* Please provide documents to prove authority to sign on behalf of patient} Witnessed _________________________Date: ____________ |