In case of emergency...
Authorizaton for Release of Private Health Information
o I authorize Capital Area Health Network, its agents or subsidiaries to release/receive all confidential healthcare records of the above listed patient.
o I understand that I have the right to revoke/cancel this authorization or limit this authorization to specific providers/facilities at any time except to the extent that prior action has been taken in reliance on this authorization. I understand that in order to revoke this authorization, I must do so in writing by notifying Capital Area Health Network prior to any actions or requests made regarding my information.
o I authorize the release of all information which may include information relating to sexually transmitted diseases, AIDS (Acquired Immunodeficiency Syndrome) or HIV (Human Immunodeficiency Virus), alcohol/drug treatment or use, behavioral or mental health services (including psychotherapy notes) and other communicable disease.
o I understand that authorizing the disclosure of this health information is voluntary and that I may refuse to sign this authorization. Capital Area Health Network nor any affiliated healthcare providers can make me sign this authorization as a condition to obtain treatment, making payments on any bills, or gaining eligibility for benefits unless allowed by law.
o I understand that by authorizing the disclosure of this protected health information, all of my records, including but not limited to history and physical exams, progress notes, laboratory reports, x-ray reports, immunization records, billing records and any other information pertaining to my health may be released to the identified person(s)/entities.
o I understand that information used or disclosed pursuant to this authorization may be subject to re-disclosure by recipient and would then no longer be protected by federal regulations.
o This authorization will remain active unless documented changes are made. This information will not be released without the appropriate signature.
o By signing below, I agree that I have received a copy of this authorization to release my information. I understand that copying charges will be applied according to Capital Area Health Network’s policies and procedures.