Space for patient sticker
Patient
Information
Section 1
Authorization to Release Protected Health Information
Please complete all sections below.
Patient Name _____________________________________________________________________________________
Last
First
Birth Date _______________________ Phone ___________________________________________________________
☐ Continuation of Care
Name ______________________________________________________________
City/State/Zip _______________________________________________________
Information to Release
Section 3
Phone _________________________ Fax ________________________________
Treatment Dates: From: (mm/dd/yyyy)____________________________________
To: (mm/dd/yyyy)______________________________________
For continued Care:
☐ Emergency room
☐ Immunization Record
☐ OP/Procedure Report
☐ Lab Reports
☐ Discharge Summary
☐ Imaging Results
☐ History and Physical
☐Consultation(s)
☐ Other________________________________________________________
Purpose:
Address ____________________________________________________________
Fees:
Release to
Section 2
I authorize Longmont United Hospital to Release Medical Record Information to:
I understand that the information in my health record may include information relating to
sexually transmitted disease, acquired immunodeficiency syndrome (AIDS) or human
immunodeficiency virus (HIV). It may also include information about behavior or mental
health services and treatment for alcohol and drug abuse.
The following fees are
applicable and authorized by
Colorado State Law:
$14.00 – 1 to 10 pages
$.50/pg – 11 to 40 pages
$.33/pg – each add’l page
☐ CD
Confirmation of Release:
ID Verified:
_____________________________________
______________________
Signature of staff
Notes:
Confirmation:
Staff Member Use:
☐ Insurance
☐ Legal
☐ Personal Use
☐ Other
__________________
☐ Fax
☐ Paper
☐ E-mail
Date: _______________________
I understand that: 1.) My signature on this form is strictly voluntary. 2.) I may revoke this authorization at any time in writing, and if I do, it will not
have any effect on any actions taken prior to receiving the revocation. Further details may be found in the Notice of Privacy Practices. 3.) If the
requester or receiver is not a health plan or health care provider, the released information may be disclosed by the recipient and may no longer be
protected by federal privacy regulations. 4.) If I do not sign this form, my health care, the payment for my health care or my ability to enroll for
benefits will not be affected. 5.) I may inspect or obtain a copy of the health information that I am being asked to disclose.
Expiration: Without my express revocation, this consent will automatically expire upon satisfaction of the need to disclosure, but in any event will
expire 180 days from the hereof, unless otherwise specified: __________.
Signature: __________________________________________________________ Relationship to Patient: __________________________________
Date: ______________________________
Longmont United Hospital
C/O Health Information Management
(AKA Medical Records)
303.651.5069 Phone 303.651.5230 Fax
YMMS4SWPXD66-362-35