AUTHORIZATION FOR RELEASE
OF PATIENT RECORDS
BRATTLEBORO NATUROPATHIC
CLINIC
Patient/Client name: DOB:__________________
I, _______________________, hereby authorize
the release of my medical health records from/to Brattleboro Naturopathic
Clinic including:
-
All records for my evaluation,
care and treatment including drug information; emergency room records;
nursing notes; laboratory results (individually copied); pathology reports;
and x-ray reports.
-
Laboratory test results
-
Pathology reports
- X-ray reports
- HIV test results ____ (please
initial) ?
Drug addiction/recovery information _____(please initial)
- Mental Health records ____
(please initial)
For the dates of ________________ to
________________.
I understand that:
- I may refuse to sign this
authorization and that my refusal to sign will not affect my ability
to obtain treatment or payment or my eligibility for benefits unless
the sole purpose of treatment is to provide information to a third party.
I understand that refusing to provide information to a physician may
result in redundancies or deficiencies in my care. I may inspect
or copy any information used/disclosed under this authorization and
understand there may be a fee for copying my health information.
- This authorization is valid
unless and until it is revoked, in writing, and properly presented to
the records office of The Brattleboro Naturopathic Clinic.
- If the person or the entity
that receives the information is not a health care provider or health
plan covered by the federal privacy regulations, the information described
above may be redisclosed and no longer protected by those regulations
and do not hold Brattleboro Naturopathic Clinic legally liable
for such redisclosure.
- I may revoke this authorization
in writing at any time by submitting a written notice of my revocation,
except to the extent that action has been taken in reliance on this
authorization.
Please release this information to: Records
released From:
_________________________________ ____________________________________
_______________________ _________________________
_______________________ _________________________
_______________________ _________________________
The information will be used/disclosed
for the following purposes:
- Continuing medical care
- Other:
_______________________________.
Signature of Patient (or his/her
authorized representative, or parent or guardian) Date
Please specify relationship to patient/client if a minor.:
The authorization expires ___________________________.
******* $20 chart copying fee may be applicable *******