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
□ Other: ____________________________________________
Additional Information to Be Disclosed:
□ Billing Records
□ Radiology Films / CDs □ Receive Images electronically via Powershare sent to personal email:
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 Substance Use Disorder documentation subject to the restrictions of 42 CFR Part 2 from Stacie Matthewson Institute. Initial: _______ □ Release Psychotherapy Notes which are defined by the Privacy Rule as psychotherapy notes recorded by a health care provider who is a mental health professional documenting or analyzing the contents of a conversation during a private counseling session or a group, joint, or family counseling session and that are separate from the rest of the patient’ s medical record. Treating provider approval is required for release. Psychotherapy notes are not used to diagnose or track treatment and are not considered to be part of the medical record.
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: ________________________________ Method of Delivery Patient requests will be fulfilled via MyChart( if active) unless specified: □ Mail. □ Patient Pick-up at Regional HIM Dept., Sierra Tower, Grd Floor.
□ Email
*** 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: ___________________________________
□ Tracking only / Records released
Form Number: 100-014
HIM / Medical Records / ROI Renown Regional Medical Center 1155 Mill St. Mail Code 012 Reno, NV 89502
Phone: 775-982-2790 Fax: 775-982-3759 Email: statuscheck @ renown. org
Revised 4 / 2025