GVH-Clinics_Authorization_Disclose_Health

HOSPITAL & CLINICS AUTHORIZATION TO DISCLOSE HEALTH INFORMATION

Gunnison Valley Health Medical Records711 N. Taylor St.Gunnison, CO 81230Phone: 970-641-7257 or 970-641-7252Fax: 970-641-7273
Patient Name*
Date of Birth*

MonthDayYear
Date
Address*

Mailing Address

Street Address Line 2

CityState

Zip
Email*
example@example.com
Phone*
Format: (000) 000-0000.
Records Request
I request my records FROM:*

Gunnison Valley HospitalFamily Medicine ClinicCampus Health ClinicGunnison Valley OrthopedicsOncologyGeneral SurgeryOphthalmologyWomen's Health ClinicDermatologyUrologyEar Nose & Throat (ENT)Other
I request my records to be sent TO:*

Self (Patient Only)Other: Provide Details below
I request my records to be released to me by the following method:*

EmailFaxMailPick Up
Name and Details of Other Person or Facility:
First/Last Name or Facility Name
Address

Address

Street Address Line 2

CityState

Zip
Phone
Format: (000) 000-0000.
Fax
Email
example@example.com
I request my records to be released to another facility by the following method:

EmailFaxMailPick Up
From

MonthDayYear
Date
To

MonthDayYear
Date
Select What Type of Records:*

Lab Results / PathologyRadiology Reports (MRI, CT, X-Ray, Ultra SOund)Radiology Images on CDRadiology Images via email link (Ambra)Emergency Room ReportUrgent Care / Mountain Clinic ReportOperative / Procedure ReportRespiratory / CardiologyClinic Office Visit NotesHistory and PhysicalDischarge SummaryMedication ReportImmunization RecordRehab Notes (PT/OT/ST)Itemized Bill/Claim Form (UB/1500)Drug / Alcohol TreatmentFamily Planning / Reproductive HealthGenetic TestingHIV / AIDS InformationSickle Cell InformationSTD / Communicable DiseaseOther (Specify Below):
If "Other" Please Specify
I consent to release information relating to psychiatric or psychological testing or treatment, alcohol, and or drug abuse diagnosis, prognosis and treatment, and /or HIV/ AIDS results, genetic testing/results, Sickle Cell anemia testing /results.*

YesNo
***NOTE: IF this section is not completed, then records of this type, if they exist for this patient, will not be released. ***
Purpose for Release*

Treatment / Further Medical CarePersonalInsuranceLegalOther
If "Other" Please Specify
Disclosers

Acknowledgments & Authorization Signature

By signing this Authorization, I acknowledge that I have read this Authorization form and understand that:
- I may refuse to authorize the disclosure of some or all of the above health information but that my refusal may result in improper diagnosis or treatment, denial of coverage or claims for health insurance benefits or other insurance, or other adverse consequences.
- I may revoke this authorization at any time, either orally or in writing, by notifying GVH in the manner described in GVH's Notice of Privacy Practices, except to the extent that GVH or any other person has already acted in reliance on it. I understand that my revocation may be the basis for the denial of health or other insurance coverage or benefits.
- There is the potential that information disclosed pursuant to this Authorization may be redisclosed by the recipient(s) of the information and that as a result, the information may no longer be protected.
- Incomplete forms cannot be processed.
- The disclosing entity may charge a fee for copying the requested records.
- A copy, fax or scan of this Authorization will be considered as valid as the original.
- I have the right to receive a copy of this signed authorization.
PLEASE ALLOW 10 DAYS TO FULFILL RECORDS REQUESTS
Signature of PatientGuardianAuthorized Representative*

Clear
Relationship*
Date*

MonthDayYear
Date
Authorized Representative's Legal Authority:

Medical Durable Power of Attorney AgentHealthcare Proxy Decision MakerBenefactor of EstateGuardianParent of MinorConservatorSurrogate Decision Maker for Healthcare Benefits
Should be Empty:

HOSPITAL & CLINICS AUTHORIZATION TO DISCLOSE HEALTH INFORMATION