Columbia Medical Associates po box 2808 Spokane, wa 99202 Tel: (509) 688-6700 Fax: (509) 688-6788




Дата канвертавання18.04.2016
Памер17.28 Kb.

Columbia Medical Associates
PO Box 2808 Spokane, WA 99202

Tel: (509) 688-6700 Fax: (509) 688-6788


Authorization for Columbia Medical Associates to Obtain or Disclose My Health Care Information

Columbia Medical Provider: _______________________________________

Patient name: ____________________________________________________ Date of birth: ____________________________
I request and authorize Columbia Medical Associates to: Obtain From or  Release To

Name: ____________________________________________________________________________________

Address: __________________________________________________________________________________

City: ____________________________ State: ___________ Zip Code: _________________________________

Phone: _________________________ Fax: ______________________________________________________
You may use or disclose the following health care information:


  • All health care information in my medical record (Includes 3 year history of records is sent when transferring care)

  • Health care information in my medical record relating to the following treatment or condition: _________________________________________________________________________________________

  • Health care information the following date(s): ____________________thru ______________________________

  • Other: ____________________________________________________________________________________

I understand that my medical record may include information on the diagnosis/treatment related to psychiatric, psychological or mental conditions, drug and or alcohol use or abuse, sexually transmitted diseases (STD), acquired immune deficiency syndrome (AIDS), and or HIV status and genetic testing. 

 

Please exclude health care information regarding testing, diagnosis, and treatment for (check all that apply):



  • HIV (AIDS virus)

  • Psychiatric disorder/mental health

Reason(s) for this authorization (check all that apply): At my request Change of provider AttorneyOther (specify) _______________

This authorization ends:  on the following date: _________________ or,  when the following events occurs: _____________



If neither of the above is checked, this request will expire in 90 days from the date of signature.

My Rights: I understand I do not have to sign this authorization in order to get health care benefits (treatment, payment or enrollment).

I may revoke this authorization in writing. If I did, it would not affect any actions already taken by Columbia Medical Associates based upon this authorization. I may not be able to revoke this authorization if its purpose was to obtain insurance. Ways to revoke this authorization are to write a letter to Columbia Medical Associates. Once health care information is disclosed, the person or organization that receives it may re-disclose it. Privacy laws may no longer protect it.

Patient or legally authorized individual signature Date

Printed name if signed on behalf of the patient Relationship (parent, legal guardian, personal representative)

I wish to receive and electronic copy of my medical records. If this is selected I must provide an email address to send a secure password to and physical address to mail disc to.

Email Address: ____________________________________Physical Address: __________________________________



*
4-30-15
*A fee for the cost of processing this request may be charged*


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