Online Medical Records Request | Thayer County Health Services

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

Patient Name(Required)

DOB(Required)

Phone Number(Required)

To Release Records From- Name of Facility(Required)

Address(Required)

City(Required)

State(Required)

Phone Number of Facility(Required)

Fax Number of Facility(Required)

Release Record To: Name of Facility(Required)

Address(Required)

City(Required)

State(Required)

Phone Number of Receiving Facility(Required)

Fax Number of Recieving Facility(Required)

Dates of Service(Required)

Description of information that may be used/disclosed for dates (if applicatable):

Complete medical record

H&P

Final summary

Radiology / lab results

Dictated & signed progress notes

Other

The information will be used / disclosed for the following purposes:

Insurance

Moving / transferring to another facility

Judicial proceedings

Other

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:

HIV/AIDS related information and/or records

Psychotherapy notes/mental health information and/or records

Drug/Alcohol diagnosis, treatment or referral information (Federal regulations require a discription of how much and what kind of information is to be disclosed

Genetics testing information and or/records

How much and what kind of information to be released (Drug/Alcohol diagnosis, treatment or referral information):

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 180 days.

If authorization is to expire, note date here:

Patient Name(Required)

First Last

Date(Required)

Representative Submitting Form For Patient

First Last

Relationship to Patient

Notice

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