AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION (“ Authorization ”) NOTE : ALL sections must be completed
Patient Name : ____________________________________________________________________ Birth Date : ______________________ Printed ( First ) ( MI ) ( Last Name ) Address : _________________________________________________________________________ Telephone #: ____________________ Street Address City State Zip Code
I authorize : Renown Health to ( circle one ) SEND TO -or- RECEIVE FROM the below entity :
____________________________________________________________________ Telephone #: _________________ Fax : ______________ Full Name / Entity Address : ___________________________________________________________________________________________________________
Street Address City State Zip Code
Purpose of Request to Release :
□ Treatment □ Personal / Patient Request □ Legal / Attorney □ Insurance □ Other ( specify ): ________________________________________________________________________________________________________
For Date ( s ) of Service from : ________________________________ to ____________________________________ [ Dates MUST be specified ]
Information To Be Disclosed :
□ Admission History & Physical □ Emergency Room Records □ Consultations □ Operative Reports
□ Progress Notes □ Radiology & X-Ray Reports □ Laboratory Reports □ Discharge Summary
□ Entire Medical Record ( Does not include billing or Radiology Films / CDs )
□ Other :: ____________________________________________
Additional Information To Be Disclosed :
□ Billing Records
□ Radiology Films / CDs
I Specifically Authorize Release of These Records ( these records will NOT be released unless you initial & check the box to consent to release ): |
Initial : _______ |
□ Release Drug , Alcohol & Substance Abuse Records |
Initial : _______ |
□ Release Communicable Disease Records , including without limitation , HIV / AIDS Records |
Initial : _______ |
□ Release Genetic Testing Records |
Initial : _______ |
□ Release Psychiatric & Mental Health / Behavioral Health Records . Treating provider approval is required for release of Psychiatric & |
Mental Health / Behavioral Health Records . |
I UNDERSTAND THAT :
● This Authorization will become effective immediately and will expire on _____________________ [ Date ]. If no date is specified , this authorization will expire one ( 1 ) year from the signature date .
● I may revoke this Authorization at any time , in a written revocation sent to the Custodian of Records . However , I understand that my health information might have already been released .
● Information released by this Authorization might be re-disclosed by the recipient and might not be protected by state and federal privacy laws . I agree to release Renown Health from liability for release and disclosure of the released information .
● I am not required to sign this Authorization as a condition to obtain treatment , services or for eligibility of benefits . My signature on this Authorization is voluntary .
Signature of PATIENT ONLY : _____________________________________ Print Name :_____________________________ Date : _____________
Signature of Person Who Is NOT the Patient : _____________________________________________________________ Date : _______________ Print Name : _________________________________________ Authority to Sign : ____________________________________________________
Proof of Authority MUST be attached ( except for parents ) Address : ________________________________________________________________________ Tel No : ________________________________
*** Completed by Staff Member Fulfilling & Verifying Authorization & Completeness *** Date : ________________ Time : ___________ Verified By : _______________________________________________________
MR #: ___________________________________
Account #: ______________________________________________________ List Document Used to Verify ( attach a copy ): ____________________________________________________________________________________ Provider Signature for Release of Psychiatric / Mental Health Records : ________________________________________________________________ Printed Provider Name : ____________________________________________________________ Date : ___________________________________
Renown Regional Medical Center 1155 Mill St . MS O12 Reno , NV 89502 Fax : 775‐982‐3759
Form 100‐014 Revised : 5 / 2019
□ Tracking only / Records released
□ Mail
□ Pa�ent Pick‐up at Harvard Way