Authorization of Release of Protected Health Information
Patient Name __________________________________ SS# ______________________
City _______________________________________ State _______ Zip ____________
Phone ____________________ Date of Birth ___/___/_____ CMP record # ___________
I hereby authorize Columbia Medical Practice: Department of Internal Medicine to release the following data:
To ____________ Self or
City _______________________________ State _________________ Zip ____________
- I understand that this authorization gives my permission to release any PHI that is contained in my Medical Record unless I specifically indicate "NO" next to one or more of the categories noted below:
____Substance Abuse Information
- This authorization is voluntary and being made at the request of the individual.
- The released PHI may no longer be protected by Federal Privacy Laws and may be re-disclosed by the individual or organization authorized to receive the PHI.
- This authorization will automatically expire one year from the date signed.
Effective October 1, 2008 the undersigned will be billed a minimum of $.73 per page and postage, if applicable.
Signed ______________________________________________ Date ______________
(If not patient, state relationship)
Witness _____________________________________________ Date ______________