AUTHORIZATION to OBTAIN PROTECTED HEALTH INFORMATION (PHI) from a NON-BMC HEALTHCARE PROVIDER

Patient Name:

______________________________________________________________________________________________________

Last First MI

Address: _________________________________________________________________________________________________________

Street (include Apt #, if applicable)

_________________________________________________________________________________________________________

City State Zip Code

Birth Date ______/______/_________ Telephone #: ______________________________ MR#_______________________________

ALTERNATE ADDRESS: (Please indicate, if you wish your information sent to a different address instead of the one listed above.

_________________________________________________________________________________________________________________

Street (include Apt #, if applicable)

_________________________________________________________________________________________________________________

City State Zip Code

I hereby authorize

__________________________________________________________________________________________

Name of Facility

_______________________________________________________________________________________________________________

Street Address City State/Zip Code

to release my protected health information to Boston Medical Center: (Releasing Facility/Provider, please have information sent to:)

Attention: ______________________________________ Department_________________________________

Boston Medical Center/One Medical Center Place/Boston, MA 02118

PURPOSE OF DISCLOSURE (Please check one)

 Continuity of Care  Consultation  Other (specify) _________________

INFORMATION TO BE RELEASED

(Please be specific and enter date of service if known):

 Entire medical record

__________________, excluding ________________________________

 Medical Record Abstract (e.g. H&P, Operative Rpt, discharge summary Consults, labs, x-rays, pathology)

 Clinic notes, specify clinic name__________________________  Pathology Reports

 Consultation Reports____________________________________  MRI Reports ____________________

 Medication Records____________________________________  Itemized Bill

______________________

  Other (specify content)_________________________________________________________________________________

I hereby authorized Boston Medical Center to obtain specifically protected or privileged categories of information that I have

initialed below:

_

_______________HIV test results (PATIENT AUTHORIZATION REQUIRED FOR EACH RELEASE REQUEST.)

___________________Alcohol & Drug Abuse Records Protected by Federal Confidentiality Rules 42 CFR Part 2

(FEDERAL RULES PROHIBIT ANY FURTHER DISCLOSURE OF THIS INFORMATION UNLESS FURTHER

DISCLOSURE IS EXPRESSLY PERMITTED OR WRITTEN AUTHORIZATION OF THE PERSON TO WHOM IT

PERTAINS OR AS OTHERWISE PERMITTED BY 42 CFR PART 2).

__________________ Psychiatric Records or Information _______________ Sexually Transmitted Diseases (STDS)

Confidential Details of:

________Psychotherapy notes (notes recorded by a mental health professional documenting or analyzing the contents of a conversation

during a private counseling session or group, joint, family counseling, and that are separate from the medical record.)

_______ Other professional services of a licensed psychologist ___________ relate to diagnosis/or treatment of Hepatitis

_______ Social Work Counseling/Therapy _______Genetic Counseling/records

_______ Domestic Violence Victim’s Counseling Records

_______ Commonwealth of Massachusetts Sexual Assault Evidence Collection Kit/Sexual Assault Counseling

I understand that I cancel this authorization in writing at any time, except to the extent that the above healthcare provider has already sent the

information to BMC. I understand that authorizing the disclosure of this health information is voluntary, I can refuse to sign, and Boston

Medical Center will not condition my treatment, payment, health plan enrollment, or eligibility for benefits on my providing authorization for the

requested use or disclosure. I understand that health information used or disclosed pursuant to this authorization may be subject to

redisclosure by the recipient, and no longer protected by Federal Confidentiality regulations; however the recipient may be prohibited from

disclosing substance abuse information.

If I fail to specify an expiration date or event, and unless otherwise revoked, this authorization will expire

six months from the date of the

signature listed below. I have carefully read and understand the above, have had any questions explained to my satisfaction, and do herein

expressly and voluntarily authorize disclosure of the above information about, or medical records of my condition to those persons or agencies

listed above.

Signature of Patient__________________________________________________________Date__________________

(Patient signature is required for patients who are 18 years or older, or who have emancipated minor status, or a special condition as defined

by law. Parent or legal representative is required for patients under the age 18 without emancipated status or a special condition.)

Signature of Legal Representative________________________________________Relationship to Patient_________________Date______

Please make a copy of this release for your records.

Revised 02/6/04