Authorization For Release of Health Information Form

I hereby authorize Berwick Hospital Center to release the following information from the medical records of:

Patient Information

First Name *

Middle Initial

Last Name *

Name at Time of Treatment (if different)

Date of Birth

Phone *

Email (optional)

Street Address

City

State

Zip

I am requesting my records from:

Facility Name *

Facility E-mail

Address

City

State

Zip

Facility Fax

What records do you want to receive or have disclosed to the recipient noted? (Check appropriate boxes below):

If it exists, the following Sensitive Information can be disclosed:

Alcohol Abuse Drug Abuse Communicable diseases, including HIV status Genetic Testing Psychiatric/Behavioral Diagnoses

How would you like your records delivered?

I understand that there is a risk to me when my information is transmitted via an unsecure email system, and the information could be accessed by a third party during the transmission process. By checking the box to request Email I accept the risk.

Paper Electronic I will pick up in person Mail to address below

If mailing, where do you want the information sent? (Fill in boxes below):

Please provide my records to:

Myself Personal Representative (indicated below) Other Third Party (indicated below)

Recipient Name

Recipient Phone

Recipient Fax

Recipient Mailing Address *

Recipient E-mail (if applicable)

Please print your name and sign below:

Name of Patient or Personal Representative

Relationship

I understand that this authorization is revocable by me, in writing, at any time, except to the extent that action has been taken in reliance on it. I will contact the above facility immediately if I wish to revoke this authorization. I also understand that this consent will expire 6 months after the date of signatures or automatically when the records requested have been released (whichever occurs first). I understand that the information released may be re-released by the recipient and may no longer be protected by HIPAA (federal regulations). The above entity may not condition my treatment or payment for my treatment on obtaining this authorization from me, unless this authorization is requested (I) to provide research-related treatment to me or (II) because the health care being provided to me is solely the purpose of creating protected health information for a third party.

eSign of Patient or Legal Representative: *
eSign Can not be empty

Date of Signature:
Upload Identity Document *

Authorization for Release of Health Information