Survey

As required by the Health Insurance Portability and Accountability Act of 1996, your physician may not use or disclosure your health information except as provided in our Notice of Privacy Practices, without your authorization. Your signature on this form indicates that you are giving permission for the uses and disclosure of protected health information described herein. You may revoke this authorization at any time by signing and dating the revocation section on your copy of this form and returning this form to this office.

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1. AUTHORZATION FOR THE RELEASE AND/OR OBTAIN PATIENT INFORMATION

I hereby give the releasing facility permission to disclose my individually identifiable health information as listed below, I understand that once this information is disclosed, it may no long be protected by Bedrock Health Group.

I understand that this authorization is voluntary, that further treatment can not be conditioned upon signing this authorization and that there may be a cost to copy records.

AUTHORZATION FOR THE RELEASE AND/OR OBTAIN PATIENT INFORMATION I hereby give the releasing facility permission to disclose my individually identifiable health information as listed below, I understand that once this information is disclosed, it may no long be protected by Bedrock Health Group. I understand that this authorization is voluntary, that further treatment can not be conditioned upon signing this authorization and that there may be a cost to copy records. Patient Name:

Date of birth:

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2. INFORMATION TO BE RELEASED Date of Service range

Please provide DD/MM/YYYY (day/month/year):

	DD		MM		YYYY
From:	INFORMATION TO BE RELEASED Date of Service range Please provide DD/MM/YYYY (day/month/year): From: Day	/	Month	/	Year
To:	To: Day	/	Month	/	Year

3. INFORMATION TO BE RELEASED (check all that apply)

INFORMATION TO BE RELEASED (check all that apply) Emergency Room Report Mental Health Treatment Genetic Information Discharge Summary Drug/Alcohol Treatment	HIV/AIDS Operative Report Radiology Reports History & Physical Laboratory Reports	Clinic/Progress Notes Other Test Results Immunization Records
Other (please specify)

4. INFORMATION IS TO BE USED FOR;

INFORMATION IS TO BE USED FOR; Continuity of Medical Care	Damage/Claim Information	Personal
Other (please specify)

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5. AUTHORIZATION:

I understand that I can take back permission to release my medical records at any time, except to the extent that action has already been taken to comply with it.

I understand that this consent will expire 190 days from the date of my signature unless I provide notice in writing that it should be revoked.

I also understand that the written revocation must be signed and dated with a date that is later than the date on this authorization.

A copy of facsimile of this form is to be considered as valid as the original.

AUTHORIZATION: I understand that I can take back permission to release my medical records at any time, except to the extent that action has already been taken to comply with it. I understand that this consent will expire 190 days from the date of my signature unless I provide notice in writing that it should be revoked. I also understand that the written revocation must be signed and dated with a date that is later than the date on this authorization. A copy of facsimile of this form is to be considered as valid as the original. Name of Patient or Authorized Representative
Date of Signature
Relationship to Patient (if applicable)

6. PATIENT’S ACKNOWLEDGEMENT OF ACCESS TO MEDICAL RECORDS

I hereby acknowledge that I - the patient/authorized representative have inspected and/or received photocopies of the medical records from Bedrock Health Group for the above named patient.

PATIENT’S ACKNOWLEDGEMENT OF ACCESS TO MEDICAL RECORDS I hereby acknowledge that I - the patient/authorized representative have inspected and/or received photocopies of the medical records from Bedrock Health Group for the above named patient. Date;
Patient name or Authorized Representative
Date:
Witness

*2. INFORMATION TO BE RELEASED Date of Service rangePlease provide DD/MM/YYYY (day/month/year):

3. INFORMATION TO BE RELEASED (check all that apply)

4. INFORMATION IS TO BE USED FOR;

6. PATIENT’S ACKNOWLEDGEMENT OF ACCESS TO MEDICAL RECORDSI hereby acknowledge that I - the patient/authorized representative have inspected and/or received photocopies of the medical records from Bedrock Health Group for the above named patient.

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2. INFORMATION TO BE RELEASED Date of Service range

Please provide DD/MM/YYYY (day/month/year):

6. PATIENT’S ACKNOWLEDGEMENT OF ACCESS TO MEDICAL RECORDS

I hereby acknowledge that I - the patient/authorized representative have inspected and/or received photocopies of the medical records from Bedrock Health Group for the above named patient.