Authorization for the Release of Health Information
Patient Name___________________________________________
Date of Birth_____________________
Address _______________________________________________
Social Security # __________________
_______________________________________________
City
State
Zip Code
Telephone _______________________
PLACE OF TREATMENT:
RECORDS MAY BE RELEASED TO:
________________________________________________
___________________________________________
________________________________________________
___________________________________________
________________________________________________
___________________________________________
Ph #: ____________________ Fax #: _________________
Ph #:____________________Fax # : _____________
I further authorize the release of information pertaining to the following which are protected by law, EXCEPT (initial all that
apply):
_______ Information about communicable diseases and infections, as defined by statute and Michigan Department of Public Health
Rules, which include sexually transmitted infections (STI), Tuberculosis, “TB”, hepatitis B, human immunodeficiency
virus “HIV”, HIV test, acquired immunodeficiency syndrome “AIDS”, and AIDS related Complex “ARC” and
__________________________________ (specify if known).
_______ Alcohol and drug abuse treatment information protected under the regulations in code 42 CFR, Part 2 of Federal
Regulations.
_______ Mental health treatment records, psychological services and social service information, including communications made by
me to a social worker or psychologist, protected by Michigan Mental Health Code Sec. 748 of Public Act 258 of 1974.
_______ DNA test result regarding a diagnosis of _____________________________ (Such as Huntington disease, breast cancer
(BRCA1, BRCA2), colon cancer, polycystic kidneys, cystic fibrosis, etc.)
I understand that my records are protected under the Health Insurance Portability and Accountability Act (HIPAA) of 1996, and cannot be disclosed
without my written consent unless otherwise provided for in the regulations or as required by State and Federal Law. This consent is subject to
revocation in writing at any time by the person served or his/her legally designated guardian except in those circumstances in which the program has
taken certain actions on the understanding that the consent will continue unrevoked until the purpose of which the consent was given is
accomplished.
Authorization shall have duration no longer than that reasonably necessary to effectuate the purpose for which it is given or 12 months
from date signed or the following date, event or condition: ________________________.
INFORMATION REQUESTED:
DATES OF TREATMENT: ________________________________
 Entire Medical Record
 History & Physical
 Lab Reports
 Immunizations
 Billing, Invoices & Statements
 Clinic Notes
 X-Rays
 EEG/EKG
 Dental Films (specify) _____________________
 Information related to visits with prior physicians and/or treatments by other physicians ___________________________
 Records related to specific problem of ___________________________________________________________________
PURPOSE OF DISCLOSURE:
 Attorney/legal
 Insurance
 Continued Care
 Transfer new Provider/Reason____________________
 Coordination of Care with/and exchange of information with Specialists or PCP as indicated above  Other ____________
It is further understood that the information released is for the specific purpose stated above, however it may be re-disclosed by the
recipient and is no longer protected by the privacy rule. I further understand that my Cherry Street provider may not withhold
treatment, determine payment, or allow health care enrollment based on whether or not this authorization is signed.
______________________________________________________
Signature of patient or legal representative
_________________________
Relationship to patient
________________________________________
Date
___________________________________________
Witness (second witness if signed with an “X”)
_______ _____________
Date
This information has been disclosed to you from records protected by Federal confidentiality rules (Title 42, Part 2, Code of Federal Regulations [C.F.R. Part 2]). The
Federal rules prohibit you from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the
individual to whom it pertains or as otherwise permitted by 42 C.F.R. Part 2. A general authorization for the release of medical or other information is NOT sufficient
for this purpose.
Revised: 1/2013