Authorization to Release Health Information 1 Practice: Patient: Name: S.S.N.: Birth Date: (Print/type name and address of health care provider) Release to: Chris L. Ingold, or his staff Ingold Law, LLC 1525 Josephine Street, Denver, CO 80206 chrisingold@mac.com FAX (303) 328-3531 (Requestor) As the custodian/parent of the above-noted child, I authorize the above-named doctor or health care provider to release to the above-noted requester my child’s health information (as specified below) maintained by the above-named doctor or health care provider. I understand that the information to be released includes or may include information regarding the following conditions: Drug abuse, if any Alcoholism or alcohol abuse, if any Psychological or psychiatric conditions, if any (including psychotherapy notes and raw data concerning psychological/psychiatric testing) Sickle Cell Anemia, if any HIV/AIDS, if any This authorization also does authorize any oral communications with any physician or other health care provider, or with their assistants, employees, clerical staff, or other agents. Information Requested: √ Copy of history and physical, discharge summary and operative reports √ Copy of outpatient and E.R. admissions √ Copy of complete hospital chart √ Pharmacy and/or prescription records √ Entire chart, including office notes and letters √ Other (specify): any records of injuries, treatment or evaluations, including records from other providers. Dates Covered: √ All admission or care at this facility or by this doctor _____ Limited to treatment dates for conditions described below: _______________________________ _______________________________ _______________________________ The purpose or need for which information is to be used is “at the request of” the undersigned, see 45 CFR 164.508(c)(1)(iv): √ Other CFI services pursuant to Court Order Authorization - I certify that this request has been made voluntarily and that the information given above is accurate to the best of my knowledge. I understand that I may revoke this authorization at any time, e.g., pursuant to 45 CFR 164.508(b)(5), except to the extent that action has already been taken to comply with it. Without my express revocation, this consent will automatically expire upon satisfaction of the need for disclosure, but in any event: four years from the date noted below by signature (date supplied by patient); or if revoked in writing by me or my representative; or under the following condition(s): (1) ; or if ___________________________________________________________________________________________________ (2) ___________________________________________________________________________________________________ Other conditions - A copy of this signed authorization: may, may not be utilized with the same effectiveness as an original. I understand that, pursuant to 45 CFR 164.508(b)(4), I do not have to sign this authorization in order to get health care benefits (treatment, payment or enrollment). Although I prohibit redisclosure of my medical records by those receiving the above authorized information (without my further written consent), I also understand the potential for information disclosed pursuant to this authorization to be subject to redisclosure by the recipient and no longer be protected by 45 CFR 164, Subpart E. 1 This authorization has been drafted to contain the elements and otherwise meet the requirements specified at 45 CFR 164.508. PERSON AUTHORIZED TO SIGN FOR PATIENT, IF ANY _____________ DATE ______________________________ SIGNATURE OF PATIENT _________________________________ Print or type name State how authorized:_________________________