Online Medical Records Request

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

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)

Other

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 12 months.

If authorization is to expire, note date here:

Date(Required)

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.

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