CURRY HEALTH CENTER
UNIVERSITY OF MONTANA
RELEASE OF INFORMATION AUTHORIZATION
PLEASE PRINT
Date of Birth ________________
Student ID# _______________________________
Patient Name _______________________________________________
SS# _______________________________
Address ______________________________________________________
Phone (day) __________________________
Dates of Attendance at UM :
I Authorize: Curry Health Center – The University of Montana
634 Eddy Avenue, Missoula, MT 59812
Phone: (406)243-4330 Medical Records Fax: (406)243-6949 or Immunization Records (only) Fax: (406)243-2254
TO: (Please check one)
 Obtain protected health information FROM the following location
*** OR ***
 Release my CHC protected health information TO the following
Name:
Agency Name:
Address:
Phone:
Information to be:
Fax:
 Mailed
 Faxed
 Picked up
Information to be Released/Received
 All medical records _________________________________________________________________________
 Only medical records from (specify health care provider) ___________________________________________
 Only medical records related to (specify problem) ________________________________________________
 Only lab tests (specify) ______________________________________________________________________
 Only x-ray films (specify) ___________________________________________________________________
 Pap/Annual Exam (most recent) Including:  Colpo  LEEP  Pap Results  Pathology
 Other requests or limitations __________________________________________________________________
Purpose of Disclosure: ________________________________________________________________________________
Medical records are defined as: All health information, whether oral or recorded in any form or medium that
identifies the patient or can readily be associated with the patient and relates to the patient’s care. This includes
health care information associated with drug/alcohol abuse, mental or psychiatric care, abortion, and HIV status
an/or diagnosis of AIDS and /or other sexually transmitted diseases including hepatitis, unless restricted above.
If one of the above facilities is requesting this authorization be completed, an individual has the right not to sign with the
understanding that an individual’s health care and the payment for health care will not be affected.
I understand that this authorization may be revoked by me at any time, provided that I do so in writing and submit it to the
Medical Records Department, up to the extent that the disclosure has not already been made. I also understand that my
protected health information may be re-disclosed by the recipient and no longer protected under federal law. Authorization
will expire in 6 months unless otherwise specified.
Expiration Date: _____________________
Patient Signature (if over 18) ____________________________________________________ Date _________________
or
Legal Representative/Guardian __________________________________________________ Date _________________
Relationship to Patient ____________________________________
Office Use Only Records: Mailed ____ Faxed ____ Given ____
Authorization is HIPAA Compliant
Date: _____________ By: ____________________
J:\Forms\Medical\Medical Office\Release Of Information.doc/Aug 2013