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AUTHORIZATION FOR RELEASE OF INFORMATION

I hereby authorize the use/disclosure of my health information as described below.  I understand that this authorization is voluntary.  I understand that any and all records, whether written, oral, or electronic format are confidential and cannot be disclosed without my prior written authorization except as otherwise provided by law.  I understand that a photocopy or fax of this authorization is as valid as the original.  Rushmore OB/Gyn cannot condition treatment, payment, enrollment, or eligibility for benefits on this authorization.

I understand that I may revoke this authorization in writing; except to the extent that records or information have already been provided to/from Rushmore OB/Gyn.  I understand that once Rushmore OB/Gyn receives records (if applicable), they will be protected by the Privacy Rule.  I understand that if I am authorizing Rushmore OB/Gyn to release information to another entity that is not bound by the Privacy Rule, the information is no longer protected by the Privacy Rule and that entity may re-disclose the information.  This authorization will expire once the information has been released or received or 1 year after the date of the said authorization.

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PLEASE RELEASE RECORDS FROM (PROVIDER/CLINIC NAME):​

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PLEASE RELEASE RECORDS TO:

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INFORMATION REQUESTED:




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(Charts May include - STI, HIV/AIDS, Mental Health, Alcohol, Drug records)
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REASON FOR THE DISCLOSURE:

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