Emerald Coast Behavioral Hospital | Panama City, FL ...
Release of Information Form
EMERALD COAST BEHAVIORAL HOSPITAL
1940 Harrison Ave Panama City, Fl. 32405 • Telephone: 850-763-0017 • Fax: 850-763-5486
AUTHORIZATION to Use or Disclose Protected Health Information.
Patient Name: _________________________________________________________ Date of Service: _______________________
SSN: ____________________________________ Date of Birth: ___________________________
I hereby freely and voluntarily authorize Emerald Coast Behavioral Hospital to:
□ Release/disclose my protected health information to:
□ Obtain my protected health information from:
Name: __________________________________________________________________________________________________________________
Address: ________________________________________________________________________________________________________________
City: ____________________________________________ State: _________ Zip: _____________ Telephone: __________________________
Fax: _______________________________
The purpose of this disclosure is for:
□ Insurance Purposes
□ The Patient
□ Progress Updates
□ Medical Treatment
□ Discharge Planning
□ Continued Treatment
□ Other:
________________________________________________________________
SPECIFIC REPORTS REQUESTED:
□ Psychiatric Evaluation
□ Discharge Summary
□ History & Physical
□ Physician’s Orders
□ Psychosocial Assessment
□ Medical Record Abstract (discharge summary, H&P, pathology, consults)
□ Psychological Testing
□ Immunization Status
□ Lab/X-Ray Results
□ Substance Abuse
□ Progress Report
□ Aftercare Plan
□ Treatment Plan(s)
□ Other: ________________________________________________________________________________________
I understand that my medical records may contain information regarding testing, drug, and/or alcohol diagnosis and treatment, a communicable
or venereal disease which may include but is not limited to, diseases such as hepatitis, syphilis, gonorrhea, or the human immunodeficiency virus, also know as acquired immune deficiency syndrome (AIDS) and/or tuberculosis. I understand that such information is confidential and is protected by federal law. I understand that the provision of health care treatment to me cannot be conditioned upon my agreement to sign an authorization for the disclosure or use of my health information for the purpose other than for treatment, payment, and healthcare operations. I understand that the potential exists for health information that is release with my authorization to be re-disclosed by the recipient, and to be no longer protected by the Federal HIPPA law. I understand that I have the right to revoke this authorization at any time by giving written notice to Emerald Coast Hospital Privacy Officer, except to the extent that action has already been taken in reliance on it. This authorization will expire 180 days following discharge, unless otherwise specified below.
Other date or condition as specified: ___________________________________________________________________________________
□ I DO NOT WISH FOR MY MEDICAL RECORDS AND PERSONAL HEALTH INFORMATION TO BE SENT TO OTHER PROVIDERS.
________________________________________ _______________________________________ ________________ _________
Signature of Patient Printed Name of Patient Date (mm/dd/yyyy) Time
________________________________________ _______________________________________ ________________ _________
Authorized Representative if Patient is unable to sign Description of Authorized Representative’s Authority Date (mm/dd/yyyy) Time
________________________________________ _______________________________________ ________________ _________
Signature of Witness Printed Name of Witness Date (mm/dd/yyyy) Time
I understand that this consent is revocable (unless action has already been taken on this authorization) upon written notice to the Manager of Medical Records, Emerald Coast Behavioral Hospital 1940 Harrison Ave Panama City Fl 32405. If additional copies of records are requested, other than continuity of care and insurance purposes, patient is responsible for payment in accordance to the facility’s policy.
(Original to be placed in patient’s medical record)
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