Morgantown, WV 26506
Chestnut Ridge Hospital/Behavioral Medicine/Student Health
Authorization for Release of Confidential Information
Patient Name: _____________________________________________________________________________________
(City) (State) (Zip)
Phone: ____________________ Birthdate: ___________________ S.S.N. ___________
I, the undersigned, hereby authorize West Virginia University Healthcare to provide the following person:
This information is to be:
□ Mailed □ Hand carried by ___________________________________ □ Other____________________
(Photo ID required)
Identity of Third Party (Name/Organization to whom info is to be given)
City State Zip Fax Zip Code
___________ History and Physical __________Immunization Records
___________ Summary ___________Psychological testing
___________ Staff/Progress Notes _________ Verbal Communication
___________ Intake Evaluation ___________ Other ____________
___________ Laboratory Studies
Covering record for time period from __________ to _______ and hereby release WVUH from all legal liability
that may arise from further disclosure of said records.
HIV BEHAVIORAL HEALTH, AND SUBSTANCE ABUSE INFORMATION contained within the records
indicated above will be released through this Authorization unless otherwise indicated below.
DO NOT RELEASE ____HIV ____ SUBSTANCE ABUSE ____BEHAVIORAL HEALTH/PSYCHIATRIC
□ Chestnut Ridge Hospital □ Behavioral Medicine □ Family Medicine
□ Student Health □ Eye Institute
The requested information to be released shall consist of □ duplicated medical records or concerning my treatment in the
Chestnut Ridge Hospital.
Signature of Patient (age 14 and up) Date
Signature of Legal Representative Relationship/Proof Date
Signature of Witness Date
IN UNDERSTAND THE FOLLOWING:
on this authorization.
therefore, UHA has no responsibility or liability as a result of the re-disclosure, and such information would no
longer be protected by the HIPAA privacy rules.
year is documented:
Hospitals PO Box 8049 Atten: Director of Health Information
place prior to the revocation request.
for the medical care and I may be liable for payment of the claims.