Medical Release – Big Island Healthcare

First Name

Last Name

Date of Birth

Date

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Authorization for Use/Disclosure of Information: I voluntarily consent to authorize healthcare provider to release my health information to the recipient(s) that I have identified below.

Previous Healthcare Provider(Required)

Phone

Fax

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Name:
Big Island Healthcare

Clinic & Mailing Address:
633 Ponahawai St., Upper Level, Hilo, HI 96720

Phone:
(808) 885-3627

Fax:
(808) 969-3852

Electronic Records
Via fax to (808) 969-3852
or secure email/P2P electronics transfer

I understand and acknowledge that certain information which may be contained in the medical record requires specific authorization for disclosure and, except as otherwise provided by law, such information may be disclosed without my specific consent.

Additionally, I have the right to refuse disclosure and prevent any other person from disclosing sensitive information. Such information could include: (1) treatment for mental or emotional conditions, (2) alcohol/drug abuse, and/or (3) HIV testing and/or restuls.

DO NOT release my sensitive information

Purpose for Release(Required)

This authorization for the listed date(s) of treatment (if unknown, leave blank)
MM slash DD slash YYYY

From

Date
MM slash DD slash YYYY

To

Information to be released/disclosed (check all that apply):
Abstract (includes H&P, Operative Report, Consult Reports, Test Reports, Discharge Summary)
All Medical Records
Immunizations
History & Physical
Consultation Reports
Physician Office Notes

Operative Reports
Discharge Reports
Laboratory Results
Radiology Reports
Cardiology Reports

Other (specify):

If left blank, we will request all medical records.

Disclosure: I understand that my healthcare provider cannot guarantee that the recipient will not redisclose my health information to a third party. The third party may not be required to abide by this Authorization or applicable federal and state law governing the use and disclosure of my health information.

I do hereby agree to release, indemnify and hold harmless, Big Island Healthcare, its officers, directors, employees, agents and members of its medical staff, from and against my claims against or liability incurred by it at any time, arising out of or in connection with the disclosure of medical information authorized by my pursuant to this consent. Signing this authorization may cause the health information used or disclosed pursuant to this authorization to no longer receive the protection of federal privacy laws.

This consent may be revoked at any time by notifying us, in writing, at the address above, except to the extent that the receiving facility has already taken action in reliance on it. This consent and authorization shall automatically expire six (6) months after the date of the consent, unless revoked by the patient's authorized representative prior to that time.

Patient or Parent/Guardian of Patient(Required)

Date(Required)
MM slash DD slash YYYY

Authorization for Release of Medical Information

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