Brownsville Community Health Center

Request/Release of Protected Health Information

Authorization form to request and/or release protected health information (PHI)

Patient's Name(Required)

*Enter the name of the patient for who medical information records are requested for.

First Name Middle Name Last Name

Date of Birth(Required)

*Enter the date of birth for the person mentioned above

Maiden Name

*Enter the Patient's Maiden Name, her Parents last name if she changed her last name when married.

Patient's current address(Required)

Phone(Required)

*Best phone number to contact the person submitting the request.

Patient's Email Address

*If the patient is being helped filling this form, please enter that person's email address.

Please select the authorization or request you like to make(Required)

*Select if you like for New Horizon Health Center to receive, release or send your medical information

I am requesting copies of my New Horizon Health Center medical records for myself

I authorize New Horizon Health Center to Obtain/Request my medical information From an external provider

I am authorizing New Horizon Health Center to Send my medical records To an external provider

Please enter the Name, Address, and Phone number of the Provider you need us to Obtain/Request your medical records FROM:

Select the method we should use to Send or Release your medical information

Please enter the Name, Address and Phone number of the Provider you need us to Send your medical records TO:

If not picking up in person, please enter the mailing address, fax number or email address to send your medical information to:

*If you do not enter a mailing address or email address, the information will be send to the one entered above depending on selection.

Please enter the reason for the disclosure of your medical information:(Required)

Which or what information do you need to be transferred:(Required)

Please enter the diagnosis or treatment

Please enter the dates of treatment

Please enter the name of the research, study or other

I know that my written consent is needed to release any protected health information relating to testing, diagnosis, and/or treatment for HIV (AIDS virus), sexually transmitted diseases, psychiatric disorders, mental health, or drug or alcohol abuse. If I have been tested, diagnosed, or treated for any of the above-named conditions, you are authorized to release health care information relating to such diagnosis testing, or treatments, please enter Patient's or Patient's Representative Initials below:

Patient's or Patient's Representative Initials:(Required)

Determine the time limit for the above consent:(Required)

Please enter the date when your consent will end.

Please enter the event that determines the end of your consent (i.e. research end)(Required)

I know that I have the right to withdraw this authorization, in writing, at any time by sending such written notice to the NHHC Health Information Management Department or Compliance Office. I understand that I may refuse to sign this authorization. My refusal will not affect my ability to obtain treatment or payment or eligibility for benefits. I also know that information used or disclosed before this authorization may be subject to re-disclosure by the person who received the information and may no longer be protected by state or federal law.

Signature of Patient or Patient's Representative(Required)

Please read and check mark all below when ready to submit(Required)

I have read and acknowledge the above statements.

I declare that the information I've provided is accurate and complete.