REQUEST FOR ACCESS TO OR AUTHORIZATION TO RELEASE PROTECTED HEALTH INFORMATION (PHI) FROM CAPE FEAR VALLEY HEALTH SYSTEM (CFVHS)

REQUEST FOR ACCESS TO OR AUTHORIZATION TO RELEASE PROTECTED HEALTH INFORMATION (PHI) FROM CAPE FEAR VALLEY HEALTH SYSTEM (CFVHS)
PRINTED NAME*
BIRTH DATE*

MonthDayYear
Date
SOCIAL SECURITY NUMBER*
PHONE*
TREATMENT DATES*

MonthDayYear
Date
TREATING FACILITY*

CFV Medical CenterHighsmith RaineyBehavioral Health CareHokeBladenCommunity Mental HealthBetsy JohnsonCentral HarnettClinicOther
I authorize Cape Fear Valley Health System to RELEASE TO:
Name of Facility or Individual to RECEIVE Information*
Street*
City*
State*
Zip Code*
Protected Health Information (PHI) to be disclosed from the above patient's medical record includes:*

Discharge SummaryHistory and PhysicalEmergency Department/Express Care RecorOperative/Procedure ReportsConsultation ReportsLabs, X-rays, EKGsI authorize the release of information contained in my record related to psychiatric and/or psychological diagnosis, status,symptoms, prognosis, and treatment to date. (May require provider approval)I authorize the release of information contained in my record related to diagnosis and/or treatment for alcohol and/or drug abuse.I authorize the release of information contained in my record related to testing/treatment for communicable diseases includingHepatitis, STDs, AIDS, ARC (AIDS-related complex), or HIV.Other
The purpose for releasing this information is:*

Health CareInsurancePersonalLegalOther
I understand the following:
- My health care and the payment for my health care will not be affected by signing this form.
- CFVHS may condition the provision of health care that is solely for the purpose of creating PHI for disclosure to a third party,upon signing an authorization for disclosure of the PHI to such third party.
- CFVHS may condition the provision of research-related treatment on provision of an authorization for the use or disclosure ofPHI for such research.
- If the requester or receiver is not a health plan or healthcare provider, information used or disclosed pursuant to this authorization maybe subject to redisclosure and may no longer be protected be federal privacy regulations.
- I may revoke this authorization at any time in writing. Revocation of this release will not have any affect on any actions previously taken.
- CFVHS will provide me with a copy of this signed authorization.
- There may be a fee regulated by the state legislature for copying of my records, to include applicable taxes and mailing.
- There are risks with electronic delivery including misaddressed/misdirected messages; email accounts that are shared; messagesforwarded to others; and messages stored on portable devices having no security.
Signature of Patient or Legal Representative*

Clear
Date*

MonthDayYear
Date
Time*
State Relationship to Patient (if applicable)*
State Relationship to Patient (Authorized representative must submit copies of legal documents supporting his/her authority to act on the patients behalf)
Print Name*
Signature of Witness*

Clear
Date*

MonthDayYear
Date
Time*
Print Name*
This consent will automatically expire 90 days from date of signature, unless another date is specified below. Authorization not valid beyond selected date. (Date cannot exceed one year from date of signature)
This consent will automatically expire 90 days from date of signature unless another date is specified. Can not exceed one year:

MonthDayYear
Date
Delivery Method*

MailPick-upElectronic - CDReview on SiteEmail
Should be Empty: