We offer almost all of our forms online for your convienence.
Please note: Tackla & Associates confirms all jobs by telephone 24 hours prior to its commencement. If you do not receive a phone call from us, WE DO NOT HAVE YOUR JOB SCHEDULED.
Toll Free (800) 871-0861
:: Office (216) 241-3918
AUTHORIZATION TO DISCLOSE HEALTH INFORMATION
Name
Date of Birth
last 4 of Social Security Number
1. I authorize the use or disclosure of the above named individual’s health information as described below:
2. The following individual or organization is authorized to make the disclosure:
Name of Provider
Address of Provider
3. The type and amount of information to be used or disclosed is as follows:
Problem list
Medication list
list of allergies
immunizatoin record
most recent history & physical
most recent discharge summary
Laboratory results from
to
consultation reports from
(doctors name)
Entire Record
Other
4. I understand that the information in my health record may include information relating to sexually transmitted disease, acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV). It may also include information about behavioral or mental health service, and treatment or alcohol and drug abuse. ***NOTE: THIS IS HIPPA COMPLIANT***
5. I understand I have the right to revoke this authorization at any time. I understand if I revoke this authorization I must do so in writing and present my written revocation to the health information management department. I understand the revocation will not apply to information that has already been released in response to this authorization. I understand the revocation will not apply to my insurance company when the law provides my insurer with the right to contest a claim under my policy. Unless otherwise revoked, this authorization will expire ONE (1) YEAR from the date written below.
6. I understand that authorizing the disclosure of this health information is voluntary. I can refuse to sign this authorization. I need not sign this form in order to assure treatment. I understand I may inspect or copy the information to be used or disclosed, as provided in CFR 164.524. I understand any disclosure of information carries with it the potential for any unauthorized re-disclosure and the information may not be protected by federal confidentiality rules. If I have questions about disclosure or my health information, I can contact (insert HIM director, privacy officer or other office or individual’s name or contact information).
7. A photocopy of this authorization has the effect of an original
8. I further agree by supplying an authorization, TACKLA & ASSOCIATES may make changes to this authorization for HIPPA compliance needed to obtain any records requested.
By Electronically signing below, you verify that all the above information is valid.
signature of patient
Date
If signed by legal representation (relationship to patient)
(800) 871-0861
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