Authorization to Release/Disclose Protected Health Information

Your information*

First Name*

Last Name*

Phone*

Email*

Address*

Last 4*

Date of Birth*

Authorization*

I authorize Guadalupe Regional Medical Center, or business associate working on their behalf, to release information contained in the medical record on the patient identified above. The information released/disclosed will cover the following dates of service:

From Date*

Through Date*

Reason for this request*

Reason for this Request*

Please describe*

What information can be disclosed?*

Complete the following by indication those items that you want disclosed. The signature of a minor patient is required for the release of some of these items. If all information is to be released, then check only the first box.

What information can be disclosed?*

Please Describe*

Your initials are required to release the following information:

Mental Health Records (Excludes psychotherapy notes)
Drug, Alcohol, or Substance Abuse Records
Genetic Info (Includes Genetic Test Results)
STD Test Results/Treatment

Initial for Mental Health Records*

Initial for Drug, Alcohol, or Substance Abuse Records*

Initial for Genetic Info*

Initial for STD Test Results/Treatment*

How to receive this health information? (Choose one)*

Onsite pickup days will be available on the next Wednesday or Friday after you submitted your request.

Who can receive this health information? (Choose one)*

Mail records
Send securely to this email address
I will pick up copies of my records
Records will be picked up by someone else (Photo ID REQUIRED)
Send records to physician/facility listed

Address*

Email*

Name*

First

Last

Physician/Facility*

Address*

Consent*

Today's Date*

If you are a Legally Authorized Representative, Please Type Your Name (if applicable):

If representative, specify relationship to individual:*

Parent of minor
Guardian
Other

Please describe*

Consent*

BY SIGNING, I UNDERSTAND:*

I may revoke this Authorization at any time by providing my written revocation to the address at the top of this form. My revocation will not apply to information already retained, used, or disclosed in response to this Authorization. Unless revoked earlier, the expiration date of this Authorization will be 90 days from the date of signature.

That information used or disclosed under this Authorization may be subject to re-disclosure by the recipient and no longer protected by privacy regulations.

The information authorized for release may include protected health information related to mental health or substance use/abuse. Release of mental health records or psychotherapy notes may require consent of the treating provider or court order.

Guadalupe Regional Medical Center will not condition my treatment, payment, enrollment, or eligibility for benefits on whether I provide this authorization.