Authorization for Release of Information
I authorize the use or disclosure of the above named individual’s health information as described below. The following individual(s) or organization(s) are authorized to make the disclosure:
HealthWorks Family Medicine
2331 New Holt Road
Paducah, KY 42001
Phone (270) 441-4777/Fax (270) 441-4780
The type of information to be used or disclosed is as follows:
DISCLOSURE REQUIRING SPECIAL CONSENT
The information identified above may be used by or disclosed to the following individuals or organization(s):
I understand that I have a right to revoke this authorization at any time. I understand that if I revoke this authorization, I must do so in writing and present my written revocation to the Privacy Officer. I understand that the revocation will not apply to information that has already been released in response to this authorization. I understand that the revocation will not apply to my insurance company when the law provides my insurer with the right to contest a claim under my policy.
If I fail to specify an expiration date or event, this authorization will expire six months form the date on which it was signed. I understand that once the above information is disclosed it may be re-disclosed by the recipient and the information may not be protected by federal privacy laws or regulations. I understand authorizing the use or disclosure of the information identified above is voluntary. I need not sign this form to ensure health care treatment.
Primary Insurance Information
If policy holder of the insurance is different than patient please complete:
Secondary Insurance Information
Privacy Act and Medical Records Release for Insurance and Referring Physicians
I, [PATIENT NAME], have received the brochure regarding the patient privacy act and understand that my records cannot be released without my written permission. I also authorize the release of all medical records to referring physicians and to my insurance company. I further authorize insurance payments to be made directly to HealthWorks Family Medicine and understand that copays/patient balances are due at the time of service.
Consent to Use
and Disclosure of Health Information For Treatment, Payment, or Healthcare Operations
I understand that as part of my healthcare, this organization originates and maintains health records describing my health history, symptoms, examination, and test results, diagnosis, treatment, and any plans for future care or treatment. I understand that this information serves as:
- A basis for planning my care and treatment.
- A means of communication among the many health professionals who contribute to my care.
- A source of information for applying my diagnosis and surgical information to my bill.
- A means by which a third party payer can verify that services billed were actually provided.
- A tool for routine healthcare operations such as assessing quality and reviewing the competence of healthcare
- I have reviewed the office policies and payment policies of the office of HealthWorks Family Medicine. I understand that noncompliance to the policies may result in discharge from the practice of HealthWorks Family Medicine.
In accordance with HIPAA, I wish to be contacted in the following manner (check all that apply):
Please list below those whom you would allow us to release test results and medical information to (i.e.: spouses, children, parents, friends):