Please fill out the information below relating to your medical record request for yourself or for your minor children. You may also make a request for patients your are the legal guardian for.

Authorization for Use or Disclosure of Protected Health Information

Thayer County Health Services- Authorization for Use or Disclosure of Protected Health Information

Description of information that may be used/disclosed for dates (if applicatable):
The information will be used / disclosed for the following purposes:
The following item must be selected to be included in the use and/or disclosure of other health information. Other rules may apply that prohibit the use/disclosure of PHI related to these conditions:

Notice

I understand that if the person or entity that receives this information is not a health care provider or health plan covered by federal privacy regulations, the information described above may be re-disclosed and no longer protected by these regulations. However, the recipient may be prohibited from disclosing substance abuse information under the Federal Substance Abuse Confidentiality Requirements (42 CFR part 2).

Notice

I understand that I may refuse to sign this authorization and that my refusal to sign will not affect my ability to obtain treatment or payment or my eligibility for benefits. I may inspect or copy any information used/disclosed under this authorization.

Notice

I understand that I may revoke this authorization in writing at any time, except to the extent that action has been taken in reliance of this authorization. If no date is noted below, this authorization will expire in 12 months.
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Patient Name(Required)
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Representative Submitting Form For Patient

Notice

A copy of this signed form will be available to the patient. TCHS reserves the right to charge for copies of PHI.