Authorization for Use or Disclosure of Protected Health Information

This field is for validation purposes and should be left unchanged.

Patient Name*

Address*

DOB*

Phone*

Email*

I, or my authorized representative, request and authorize the release of my health information as set forth on this form.

Release Information From :

Name of Provider or Individual*

Address*

Release Information To :

Name of Provider or Individual*

Address*

I request that you release the following:*

release my medical record

release only the following items from my medical record (please specify below):

Only the following Medical Records Should be Released:

Please answer if you selected "release only the following items from my medical record"

Check here to indicate how you want your records to be transferred:*

Fax

Email Address or Fax Number to send records to if selected above

Email: EFP will only send end-to-end encrypted email to better protect your privacy. You will receive an email notifying you to log into our secure email network to retrieve your records. With any electronic communication, there is the risk of identity compromise or other interception (e.g., hacking, phishing). By signing this form, you indicate that you accept those risks and want EFP to email your records as indicated. For security purposes, we will only be able to email records to the email address you have on file in your chart, if you are requesting we email you your own records. The email address you enter here must match the email address in your chart. If you are requesting that we email your records to a third party, we may attempt to confirm the validity of that email prior to releasing the records but you remain responsible for ensuring the accuracy of the email address you enter. Please note that if we have any questions or concerns about the record request or email address, we will not email the records but will send by fax or CD. This is meant to ensure the privacy and security of your protected health information.

Please note that not all other facilities will accept records on CD or by email, and we will be unable to send them on CD or by email in this case. If you do not check any option, records will be mailed in paper form or will be faxed.

For the following to be included in your record release you must check next to the box next to the applicable item:

including HIV

including alcohol/drug treatment

including records from mental health programs

including genetic testing

This protected health information is being used or disclosed for the following purposes*

Records to Specialist concerning treatment

Permanent Transfer Out of the Practice

Records to Specialist concerning treatment for

Reason*

Reason*

Insurance Change/Type of Insurance

Moving out of area

Dissatisfied with Care

Billing Issues

Other

Insurance Change/Type of Insurance*

Other*

Reason

Reason

Insurance Change/Type of Insurance

Moving out of area

Dissatisfied with Care

Billing Issues

Other

Insurance Change/Type of Insurance*

Other*

I understand that if my records contain information about alcohol and drug abuse, mental health treatment from a mental health program, genetic testing information, and/or HIV/AIDS status, I authorize the Practice to release such information as part of my medical record only if I check the appropriate box as set forth above. The disclosure of any part of the medical record deemed to be “psychotherapy notes” will require a separate authorization.

This authorization shall be in force and effect until 60 days after the date of signature at which time this authorization to use or disclose this protected health information expires unless revoked by request earlier.

Fees: The practice will waive the fee for the first copy being sent to another medical facility. Records released directly to patients will be subject to a fee of $6.50, regardless of form (paper, CD, etc). Records released to third parties will be subject to a fee of $.75/page, up to a maximum of $50, regardless of form.

Is the signer the Patient or a Personal Representative*

Patient

Personal Representative

Description of Personal Representative's Authority (e.g., legal guardian, executor, etc)

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Signature of Patient or Personal Representative

Print Name of Patient or Personal Representative*

Date*

Description of Personal Representative’s Authority (e.g., parent, legal guardian, executor, etc)*

A copy of this form will accompany your records.

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Authorization for Use or Disclosure of Protected Health Information

I, or my authorized representative, request and authorize the release of my health information as set forth on this form.

Release Information From :

Release Information To :

Practice Information

Patient Resources

Primary Care Services

Ancillary Services

Contact Us

Practice Information

Patient Resources

Primary Care Services

Ancillary Services

Contact Us