rheumatology patient history

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AUTHORIZATION FOR THE RELEASE OF INFORMATION
Please PRINT all information

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PATIENT NAME (LAST, FIRST)

DATE OF BIRTH

PATIENT ID# (OPTIONAL)

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I HEREBY AUTHORIZE



TO RELEASE INFORMATION TO:

PERSON/FACILITY/AGENCY:

STREET ADDRESS:

CITY, STATE, ZIP:

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Phone

FAX

PURPOSE OR NEED FOR INFORMATION REQUESTED:

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TYPE OF RECORD:

OFFICE MEDICAL

IN/OUT PATIENT

OTHER

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THE MEDICAL RECORDS ARE DATED:

THE FOLLOWING INFORMATION MAY BE RELEASED: (INITIAL EACH TYPE TO BE RELEASED)

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LABORATORY/PATHOLOGY

MEDICAL IMAGING

OTHER

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THE MEDICAL RECORDS ARE DATED:

MENTAL HEALTH/PSYCHIATRIC (excluding Psychotherapy notes

MENTAL HEALTH RECORDS -- In the event that information released constitutes privileged mental health patient communications, the confidentiality of this
record is required under Chapter 899 of the Connecticut General Statutes. This material shall not be transmitted to anyone without written authorization as provided in
the aforementioned statutes.
DRUG & ALCOHOLABUSE RECORDS -- In the event that information release is protected by the HHS Confidentiality of Alcohol and Drug Abuse Patient Record
regulations: This information has been disclosed to you from records protected by Federal confidentiality rules (42 CFR Part 2). The Federal rules prohibit you from
making any further disclosure of the information unless further disclosure of authorization for release of medical or other information is not sufficient for this purpose.
The Federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse patient.
AIDS OR HIV RELATED INFORMATION -- This information has been disclosed to you from records protected by State Law. Connecticut State LAw prohibits
you from making any further disclosure without the written consent of the patient or as otherwise permitted by said law.

I UNDERSTAND THAT I MAY REFUSE TO SIGN THIS AUTHORIZATION WITHOUT AFFECTING MY TREATMENT OR PAYMENT. FURTHERMORE, I UNDERSTAND THAT ONCE
INFORMATION HAS BEEN DISCLOSED SUBJECT TO THIS AUTHORIZATION, THE INFORMATION MAY BE SUBJECT TO REDISCLOSURE AND NO LONGER PROTECTED BY STATE OR
FEDERAL LAW.

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PATIENT SIGNATURE*

DATE:

The PATIENT has NOT SIGNED this form, please indicate the relationship of the signator to the patient

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Parent/Guardian

Administrator/Executor of Estate

Power of Attorney/Conservator

Other/Specify

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SIGNATURE OF REQUESTOR:

DATE:

WITNESS:

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PRINT NAME OF REQUESTOR:

PHONE NUMBER:

THIS AUTHORIZATION MAY BE REVOKED IN WRITING AT ANY TIME, EXCEPT TO THE EXTENT THAT INFORMATION HAS BEEN OBTAINED OR RELEASED. YOUR RIGHTS TO
REVOCATION MAY BE FOUND IN THE NOTICE OF PRIVACY PRACTICES. THIS AUTHORIZATION SHALL EXPIRE 12 MONTHS FROM THE DATE OF SIGNATURE OR UPON THE
FOLLOWING EARLIER EVENT,

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CONDITION OR

DATE:

rheumatology patient history

AUTHORIZATION FOR THE RELEASE OF INFORMATION Please PRINT all information

THE FOLLOWING INFORMATION MAY BE RELEASED: (INITIAL EACH TYPE TO BE RELEASED)

“Excellent doctor. Highly recommend. He actually listened to us and asked questions to better understand the condition. Dr. Quan is how all doctors should be, but most aren't.”

AUTHORIZATION FOR THE RELEASE OF INFORMATION
Please PRINT all information