REQUEST FOR MEDICAL AND/OR DIAGNOSTIC TREATMENT AND AUTHORIZATION TO
RELEASE MEDICAL INFORMATION
I represent and warrant that I am the legal guardian of:_______________________________
and I am authorized to request and consent for his or her medical treatment and release of
medical information. I, the undersigned, a patient, or the legal guardian of a patient hereby
request and authorize the hospital and/or physicians and physician’s assistants to
administer such treatment as is necessary and to perform medical or diagnostic treatment
or tests and such additional procedures, including administration of blood or blood
products, as are considered therapeutically necessary on the basis of findings during the
course of said treatment. I also understand that no guarantee or assurance can be made
as to the outcomes that may be obtained. Information regarding my or my child’s rights
and responsibilities as a patient at CHS is posted in all out-patient areas and is available in
a guest book in the inpatient room. The mechanism for resolving conflicts is included in
this information.
___________ (Initials)
I understand that CHS is a teaching hospital and that residents and students may be
involved in my/my child’s care under the supervision of an attending physician.
___________(Initials)
HIPAA AUTHORIZATION TO RELEASE INFORMATION
In accordance with the Health Insurance Portability and Accountability Act of 1996
(HIPAA), I authorize CHS to release the information described below, by oral and written
communication, to any of those medical facilities or persons who referred the patient for
care or who may be responsible for the patient’s care following release from CHS, all for
the purpose of coordinating care.
___________ (Initials)
I authorize CHS and/or my doctor to contact my child’s school employees/agents and
release the information as stated below as necessary for a medical emergency.
____________(Initials)
I understand CHS may release the information as stated below to referring physicians.
____________(Initials)
I understand CHS may release the information as stated below to third party payers.
____________(Initials)
Such communication may be orally and in writing on a continuing basis. I expressly
authorize the following information to be released: All medical reports or other related
information regarding my or my child’s treatment, hospitalization and/or out-patient care,
including information regarding psychological or psychiatric conditions, drug abuse
and/or alcoholism, acquired immunodeficiency syndrome (AIDS), and tests for infection
with human immunodeficiency virus (HIV).
____________ (Initials)
I understand that my or my child’s name, along with the chief complaint, may be entitled to
certain protection under patient confidentiality laws. However, to facilitate patient care, I
agree that this information may be posted on a patient flow board located at the nurse’s
station where CHS medical staff, employees and other patients and families may be able to
view this information. My permission to release this information for this purpose, in no
way affects any other confidentiality rights that I may have. If I am opposed to this, I will
notify an Access Facilitator or Charge Nurse.
____________(Initials)
FINANCIAL CONSENT
Assignment of Insurance Benefits: I hereby authorize payment directly to CHS and/or
physician providers of the group medical benefits and otherwise payable to me but not to
exceed CHS’ or physician provider’s regular charges for this period of medical services. I
understand I am financially responsible to CHS and/or the physician providers for charges
not covered by this assignment. In the event of default, and if this account is turned over
to an attorney, not a salaried employee of CHS, for collection, “I” “WE” further agree to
pay all costs of collection including reasonable attorney’s fees and waive our rights of
exemption under the law of the State of Alabama. __________ (Initials)
SIGNATURE_________________________________ DATE________ __________________
Patient, Parent, Legal Guardian
WITNESS___________________________________
219572099
DATE___________________________
These authorizations are valid for a period of six (6) months and can be withdrawn at any
time before then. I understand that the withdrawal of these authorizations must be in
writing and is effective when received by Medical Information Services.
219572099