Morgantown, WV 26506

Chestnut Ridge Hospital/Behavioral Medicine/Student Health

 

Authorization for Release of Confidential Information

CH012 (R3/12)

 

Date: _____/_____/_____

 

Patient Name: _____________________________________________________________________________________

Address: _________________________________________________________________________________________

(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)

_______________________________________________________________________________________

Street Phone

_______________________________________________________________________________________

City                         State                     Zip                 Fax                             Zip Code

Text Box: Special Instructions:

 

___________ History and Physical __________Immunization Records

___________ Summary ___________Psychological testing

___________ Staff/Progress Notes _________ Verbal Communication

___________ Intake Evaluation ___________ Other ____________

___________ Laboratory Studies

 

Special Instructions

__________________________________________________________________________

Other (Specify)

______________________________________________________________________________

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

___OTHER ____

INPATIENT                                          OUTPATIENT

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.

reason(s).

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.