Release of information form "*" indicates required fields Patient Name* First Last Patient DOB* MM slash DD slash YYYY Chart Number I understand that due to HIPAA and patient confidentiality, because I am a legal adult, I must provide written authorization for any medical information from this office to be shared with anyone other than myself. By signing this form, I understand that I am giving Dr Susan Mathison and /or other physicians at Catalyst Medical Center as well as the nursing staff authorization to discuss my medical condition to the person or persons I have listed below. I also authorize Catalyst Medical Center business office to discuss my account balance and/or financial status unless I indicate otherwise below. I authorize release for the following personnel:Name Relationship Name Relationship Name Relationship Name Relationship I understand that this authorization will remain in effect until such time as I ask for the information to no longer be given to the above person or persons. I understand that it is my sole responsibility to notify Catalyst Medical Center of this change. This has been explained to me and I fully understand this authorization form.Patient Initials* Date* MM slash DD slash YYYY STANDARD AUTHORIZATION OF USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATIONPatient Name* First Last Patient DOB* MM slash DD slash YYYY Patient Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code I authorize Catalyst Medical Center and Clinical Spa to: SEND copies of your record to (or discuss information with) the provider/person/facility below RECEIVE copies of your medical record from (or discuss your information with) the provider/person/facility below Name of Provider/Facility/Person Phone NumberAddress Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Fax NumberInformation to be disclosed: Progress Notes Pathology/Lab Report(s) Diagnostic Imaging Operative Notes Cosmetic Notes Entire Medical Record ENT Reports Dermatology Reports Allergy Reports Restrictions: Only medical records originated through Catalyst Medical Center and Clinical Spa will be copied unless otherwise requested. This authorization is valid only for the release of medical information dated prior to and including the date on this authorization unless other dates are specified. The records above may be faxed in case of medical necessity. This authorization may be cancelled at any time by submitting a written request to Catalyst Medical Center and Clinical Spa. This authorization will remain in effect until we have written notice of cancellation. I have read the above Authorization for release of medical information and do hereby acknowledge that I am familiar with and fully understand the terms and conditions of this authorization.Patient Signature* Date* MM slash DD slash YYYY Parent or Guardian signature required for any patient under the age of 18Relationship to Patient (if other than self) Printed Name of Representative CAPTCHAPhoneThis field is for validation purposes and should be left unchanged.
