Authorization for Disclosure of Protected Health Information
Authorization for Disclosure of Protected Health Information
Patient¡¯s Name: ________________________________________________
Date of Birth: _______________
I do hereby authorize:
Northern Hospital of Surry County
Northern Pediatrics Center
Blue Ridge Bone & Joint Center
Northern Gastroenterology
Surry Urological Associates
Surry Medical Specialists
Mount Airy OBGYN Center
Surry Surgical Associates
Revival
Other agency or physician: ______________________________________________________________________
Please release the following health information: (Please describe date and/or specific information.)
_________________________________________________________________________________________________
Please release the information to:
Name of Person or Facility/Department to receive health information: ___________________________________________
Address: __________________________________________________________________________________________
Telephone #: ________________________________________ Fax #: _________________________________________
Fax #: Northern Hospital HIM (Medical Records) Dept (336) 719?7456; Northern Hospital Emergency Dept (336) 789?5495;
Northern Pediatrics Center (336) 786?3796; Blue Ridge Bone & Joint Center (336) 719?0714; Northern Gastroenterology (336) 786?6747;
Surry Urological Associates (336) 786?3795; Surry Medical Specialists (336) 786?8973; Mt. Airy OBGYN Center (336) 789?3025;
Surry Surgical Associates (336) 786?3778; Revival (Elkin) (336) 835?5337; Revival (Mt. Airy) (336)783?8035.
r*ADPHI*r
The purpose of this release is:
Continuity of care
Insurance
Legal
School/Work
release
Other: _________
(Please specify)
I authorize the use or disclosure of my protected health information as described above.
I have a right to receive a copy of this authorization. I am signing this authorization voluntarily. I understand that I may
revoke this authorization at any time by presenting a request for revocation in writing to the Health Information
Management Department of Northern Hospital of Surry County. I understand a revocation will not reverse any action taken
in reliance upon this authorization. This authorization will expire in six months after the date of signing. I understand that
the information disclosed pursuant to this authorization may include information concerning mental health, use or treatment
concerning drugs and/or alcohol abuse under 42 CFR Part 2, HIV/AIDS, and/or other communicable disease, and genetic
testing results.
I understand that the information disclosure pursuant to this authorization may be re?disclosed by the person(s) receiving
this information and the information disclosed may no longer be subject to protection by federal privacy regulations or other
laws.
Signed by Patient: ____________________________________________________
Date: _______________
Signed by Personal Representative: ______________________________________
Date: _______________
Witness: ___________________________________________________________
Date: _______________
ADPHI
MR13
Authorization for Disclosure of Protected Health Information
043014
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