Document 6599118

ST. ANTHONY’S HOSPITAL (CLOSED)
AUTHORIZATION TO DISCLOSE PROTECTED HEALTH INFORMATION/MEDICAL RECORDS
PATIENT INFORMATION
Patient Name:
Patient Address:
Patient SSN:
Date of Birth:
Maiden/Other Name:
Phone Number:
INSTRUCTIONS
I hereby authorize the release my medical records to:
Release to - Name:
Release to - Address:
For the Dates of Service for requested information,_________________________________, please release the following
information in my medical record (check all that apply):
History and Physical

Emergency Room Record

Entire Medical Record

Consultation Reports

Laboratory Reports

Abstract or Summary

Discharge Summary

X-ray/Imaging Reports

Other

Operative Reports

SPECIAL INSTRUCTIONS (CHECK ALL THAT APPLY)
I
I
I
I
I
do
do
do
do
do





do
do
do
do
do
not
not
not
not
not





want HIV/AIDs information released under this authorization.
want mental health information released under this authorization.
want drug/alcohol abuse or treatment information released under this authorization.
want genetic testing information released under this authorization.
want sexually transmitted disease information released under this authorization.
PURPOSE OF THE RELEASE OF INFORMATION
Continuation of Care
At my request (patient only)

Insurance


Other
Legal


This authorization will expire within two (2) months unless otherwise indicated. I understand that this authorization is
voluntary and may be revoked by me at any time in writing except to the extent that action has already been taken in
reliance with this authorization.
I understand that St. Anthony’s Hospital has closed and that records will not be available past 12 months of
notification. I understand that information used or disclosed pursuant to this authorization may be subject to
disclosure by the recipient and will no longer be protected by the Health Insurance Portability and Accountability Act.
PLEASE PROVIDE A COPY OF PHOTO IDENTIFICATION WITH THIS RELEASE FORM
___________________________________________
Signature of Patient or Patient’s representative
(Personal & Legal Representative must include proof of status)



___________________________________
Date
Parent
___________________________________
Personal Representative
Witness
Legal Representative
Mail Form and copy of Photo ID to: St. Anthony’s Records, c/o Iron Mountain,5249 Glenmont Dr, Houston, TX
77081 (Telephone: 832.616.5429)
FORM MUST BE COMPLETED IN ITS ENTIRETY OR IT WILL BE RETURNED