Delta Health System ROI Form

Authorization for Use and Disclosure of Health Information
Patient Name *
Email Address *
example@example.com
Patient Address *
Patient City, State ZIp *
Phone No. *
Date of Birth *

Month Day Year
Date
Social Security No. *
1. I authorize the following institution(s) to use or disclose the above-named individual's health information as indicated below: (check one and specify location) *

Delta Health - The Medical Center Delta Health - Medical Group(Clinic) Delta Health - Highland Hills Delta Health - Northwest Regional Other
2. I hereby authorize the use or disclosure of my individually identifiable health information as described below. I understand that this is voluntary. I understandthat after the above-named facility discloses this information, it no longer has control over protection of the confidentiality of the information. Should the recipient re-disclose the information, it will no longer be protected by the Federal Privacy Regulations.
3. From Date of Service *

Month Day Year
Date
Through Date of Service *

Month Day Year
Date
Information to Release *

Discharge Summary Consultation/Evaluation Operative Report(s) Lab/Path Report History & Physical Progress Notes Imaging X-ray Report ER Report Entire Record Verbal Exchange Other
4. How would you like your records delivered? *

Electronic Paper USB or CD Email ( I understand that there is a risk to me when my information is transmitted via an unsecured email system, and the information could be accessed by a third party during the transmission process. By checking the box to request E-mail delivery I accept this risk)
If mailing, where do you want the information sent? (fill in boxes below):
Please provide my records to: *

Myself Personal Representative (indicated below) Other Third Party
Personal Representative Name
5. I understand that the information in my health record may include information relating to: Sexually transmitted diseases Human immunodeficiency syndrome (HIV) Behavioral or mental health services Acquired immunodeficiency syndrome (AIDS)

Treatment for alcohol and drug abuse - protected by Federal Regulation 43 CRF part 2
6. This information may be disclosed to and used by the following individual or organization:
Individual or Organization Name:
Phone Number
Address
City, State Zip
For the purpose of
7. I understand that I have a right to revoke this authorization at any time. I understand that if I revoke this authorization, I must do so in writing and present my written revocation to the appropriate Delta Health System facility. I understand that the revocation will not apply to information. that has already been released in response to this authorization. Unless otherwise revoked, this authorization will expire on the following date, event, or condition:
If I fail to specify an expiration date, event, or condition, this authorization will expire in one year.
8. I understand that authorizing the disclosure of this health information is voluntary. I can refuse to sign this authorization. I need not sign this form to assure treatment. I understand that I may inspect or copy the information to be used or disclosed, as provided in 45 CFR §164.524. I understand that any disclosure of information carries with it the potential for unauthorized disclosure access, and the information may not be protected by the federal confidentiality rules. If I have question about disclosure of my health information, I can contact the Health Information Department at the appropriate Delta Health System facility or the System Privacy Officer at 662-725- 2264.
Signature of Patient or Legal Representative *

Clear
Date *

Month Day Year
Date
If signed by Legal Representative, Relationship to patient

Clear
Should be Empty: