Medical Release Form

Authorization for Disclosure of Protected Health Information

Patient Info:

First Name

Middle Name

Last Name

Address (Number, Street)

City

State

Zip

Phone Number

Reason for Request to release Protected Health Information:

My Request Continuity of Care Legal Other (Explain Below)

Explanation:

Release PHI to:

Name of Person or Institution:

Address

Phone Number:

Authorization:

I hereby authorize the Cinnaminson Fire District No. 1 to disclose the health information as contained in the Electronic Patient Care Report. I understand that such disclosure may include information of a more sensitive nature, such as records related to: mental or behavioral health, substance use disorder (drug or alcohol abuse), genetic diseases or testing, sexually transmitted diseases (STDs), human immunodeficiency virus (HIV), acquired immunodeficiency syndrome (AIDS), and birth control and abortion (family planning). I specifically authorize the disclosure of such sensitive health information to the person or institution noted above.

I understand that my authorization will automatically expire six (6) months from the date of signature on this form. I understand that I have a right to revoke this authorization at any time. I understand that to revoke this authorization, I must do so in writing and submit my written revocation to the Cinnaminson Fire District No. 1. I understand that the revocation will not apply to health information that has already been disclosed in response to this authorization.

I understand that this authorization shall operate as a complete release of liability to the Cinnaminson Fire District No. 1, officers, employees, and agents, for the disclosure of the health information as described above.

I understand that the health information used or disclosed pursuant to this authorization may be subject to redisclosure by the recipient and may no longer be protected by federal and/or state law.

Signing this authorization is voluntary and I understand that the Cinnaminson Fire District No. 1 may not condition treatment, payment, enrollment or eligibility for benefits on my signing or refusal to sign this authorization.

By signing below, I understand that I am authorizing the Cinnaminson Fire District No. 1 to disclose the health information as describe above.

Signature of Patient or Patient’s Legal Representative (as applicable)

Date

Time

Name of Patient’s Legal Representative (Print)

Relationship to Patient or Statement of Authority to act on Patient’s Behalf (i.e. spouse, parent, legal guardian, person acting in loco parentis, etc.)

Proof of legal right to request for such information must accompany this request in the event that someone other than the Patient is requesting such information to be released.

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