Release Of Medical Records

Patient Information

This authorization is for the release of medical information.

Your Name(Required)

First Middle Last

Your Address(Required)

Street Address Address Line 2 City State ZIP Code

Birth Date(Required)

Daytime Telephone Number(Required)

Social Security Number(Required)

Organization Providing Information

Name of person or organization releasing information(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Organization Requesting Information

Name of person or organization requesting information(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Information To Be Disclosed

Check All That Apply(Required)

Operative/Procedure Reports

Pathology

Other

Special Authorization To Disclose Super-Confidential Information

ALCOHOL/DRUG/INFECTIOUS DISEASE/MENTAL HEALTH RECORDS are protected by Federal Regulation 42 CFR, Part 2. Release of such records requires specific consent. I hereby grant such specific consent as initialed below. I UNDERSTAND that these records are protected under federal and state law and cannot be disclosed without my written consent unless otherwise provided by law. I further understand that the specific type of information to be disclosed may, if applicable, include diagnosis, prognosis, and treatment for physical and/or mental illness including treatment of alcohol or substance abuse, sexually transmitted diseases, acquired immune deficiency syndrome (AIDS), or human immunodeficiency virus (HIV) infection.

AS PART OF THE MEDICAL RECORDS CHECKED ABOVE, THE FOLLOWING INFORMATION WILL BE RELEASED UNLESS STRICKEN:

HIV/AIDS related information and/or records
Mental Health information and/or records
Sexually transmitted diseases
Drug/alcohol diagnosis, treatment or referral information

Purpose Of Disclosure

Purpose Of Disclosure(Required)

Continuing Medical Treatment

Residence Relocation

Second Opinion

Patient Request

For Purposes Other Than Treatment, Payment And Operations (patient is to receive a copy of the Authorization)

Research

Disability Insurance

FMLA

Life Insurance

Marketing Promotion

Sale Of PHI

Other

I understand that this authorization will expire one year form the date of submittal.

Marketing Promotion: I have been informed Brown Fertility is not receiving any direct or indirect compensation from a third party as a result of disclosing information for this purpose.

Sale Of PHI: I have been informed that Brown Fertility is not receiving any direct or indirect compensation from a third party as a result of disclosing information for this purpose.

Other (Please Specify)

Right To Revoke Authorization

I MAY REVOKE THIS AUTHORIZATION AT ANY TIME, IN WRITING, BEFORE THE INFORMATION HAS BEEN RELEASED. I FURTHER UNDERSTAND THAT I HAVE A RIGHT TO RECEIVE A COPY OF THIS AUTHORIZATION UPON REQUEST. I HEREBY RELEASE BROWN FERTILITY FROM ANY AND ALL LEGAL LIABILITY THAT MAY ARISE FROM THE RELEASE OF THIS INFORMATION TO THE PARTY NAMED ABOVE.

Authorization & Signature

I hereby authorize the use of disclosure of my individually identifiable health information as described below. I understand that this authorization is voluntary. I understand that treatment, payment, enrollment or eligibility of benefits may not be conditioned on my signing this authorization. I further understand that if the organization authorized to receive the information is not a health plan or health care provider, the released information could potentially be disclosed and may no longer be protected by federal privacy regulations. Therefore, I release Brown Fertility from all liability arising from this disclosure of my health information.

I understand and agree that I am financially responsible for the following fees associated with my request: copying charges and postage related to the production of my information. For patients and governmental entities: 1.00 per page for the first 25 pages and 25¢ per page for each page in excess of the first 25 pages. For other entities: up to $1.00 per page for each page copied, in accordance with Florida Administrative Code 64B8-10.003.

BY SIGNING THIS AGREEMENT, I ACKNOWLEDGE THAT I HAVE CAREFULLY READ, UNDERSTAND AND AGREE TO THE ABOVE TERMS AND CONDITIONS.

First Name Of Patient

First

Last Name Of Patient

Last

Name Of Parent, Guardian or Legal Representative

Relationship To Patient

Records Are Needed By (date)

Send By

Fax

Mail

Patient Will Pick Up

Electronic Format (EMR)

Fax Number