AUTHORIZATION FOR RELEASE OF INFORMATION

Hospital Clinic Long-term Care

516 North Main Street 525 North Main Street 709 4th Ave. NE

Watford City, ND 58854 Watford City, ND 58854 Watford City, ND 58854 701-842-3000 701-842-3771 701-444-2331

Fax 701-842-4503 Fax 701-842-4025 Fax 701- 444-4629

Patient Name:______Maiden/Former Name:______

Birth Date:______Phone #:______MR#:______

(Office Use Only)

I Authorize: To Release to:

______

______

______

The type and amount of information to be used or disclosed is as follows: (include dates where appropriate)

Dates of Service: ______(date) to ______(date)

______Discharge Summary ______History & Physical ______Operative Report

______Lab Reports ______X-ray Reports ______Immunization Record

______Clinic Note(s) ______Billing Information ______Entire Medical Record for all dates

______Other (please specify)______

______

______

 Verbal discussion only – do not release any written records

Purpose of Disclosure: _____Further treatment _____Transfer of care _____Personal Records

_____Legal _____Payment of Insurance Claims _____Disability Determination

_____Other(Specify)______

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 health information management department. 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. Unless otherwise revoked, this authorization will expire on:______(specify date or event), or if no date or event is specified, 12 months from the date of signing.

I understand that authorizing the disclosure of this health information is voluntary. I can refuse to sign this authorization. I need not sign this form in order to assure treatment. I understand that I may inspect or copy the information to be used or disclosed, as provided in CFR 164.524. I understand that any disclosure of information carries with it the potential for an unauthorized redisclosure and the information may not be protected by federal confidentiality rules. If I have questions about disclosure of my health information, I can contact the HIM Director.

Photocopy is as valid as the original.

______

Signature of Patient/Guardian/Representative Date

______

If not patient, state authority/relationship Signature of Witness

_____ Check if information has been sent Form 100/Rev 11/2014