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Authorization to Use or Disclose Health Care Information.
Patient Name: _______________
Date of Birth: _______________
Address: ____________________________
I authorize my health care information may be disclosed to
Alda L Knight, MD FACP
the Other Medical Clinic, PLC
410 East Robinson, Ste B-2,
Knoxville, Iowa 50138
Phone (641)842-3700. Fax (641)-842-3363
From _________________________________________________________
FAX or Phone of prior Provider _________________________________
CHOICES: I restrict disclosure as follows:
[check all that apply]
__ Send ONLY my health care information relating to the following treatment(s) or
condition(s):
OR
♦ I AM allowing transfer of sensitive information related to Infectious or Sexually
transmitted diseases past or present.
♦ I AM allowing transfer of sensitive information related to psychiatric illness
past or present.
AND
♦ My health care information ONLY for the following date(s) or amount of time:
OR
♦ All my health care may be disclosed and used for ongoing care by the Other Medical Clinic, PLC.
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♦ This health care information may be ALSO disclosed to: (relative or another clinic for example)
____________________________________________________
♦ I understand that I have the RIGHT NOT TO SIGN this authorization. My refusal to sign will NOT affect my ability to get treatment.
♦ I understand that my records can and may be sent to my insurance company as part of the billing process and health care information collection without my specific request.
♦ I understand that my records can and may be sent to other doctors who are caring for me, including sub-specialists, for continuing medical care without my specific consent.
♦ I understand that I may revoke this authorization by writing a letter to the
physician and/or hospital stating that I want to revoke, cancel or withdraw this
authorization.
♦ I understand that this letter will not affect any actions already taken by (the above physician and/or hospital) based on this authorization before it was revoked.
♦ I understand that I may not be able to revoke this authorization if its purpose was to obtain insurance.
♦ I understand that the physician and/or hospital have no control over the information. The person or organization that I authorize to receive the information might re-disclose it. It may no longer be protected by privacy laws.
This authorization is valid for
♦ 6 months ♦ 1 year ♦ until ________(date)
The purpose(s) of this disclosure and use are:
Patient request ___ Doctor’s request ___
Continued Medical Care ____ Other Research_____
Insurance, as for eligibility ___ Legal matters _____
Signature of patient or authorized representative
___________________________________
Print Name _________________________
Date: _________________
Relationship to patient:_______________
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