Authorization for Release of Medical Information (outgoing) Patient First Name(Required) Patient Last Name(Required) Email(Required) PhoneAddress 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 personal health information to the recipient(s) that I have identified below. Previous Healthcare Provider: Big Island Healthcare Address/City/State/Zip: 633 Ponahawai Street, Suite 101, Hilo, HI 96720 & 409 Kilauea Avenue, Hilo, HI 96720 Phone: (808) 885-3627 Fax: (808) 969-3852 Recipient I authorize my healthcare information be released to the following recipient:Recipient Name/Group(Required) PhoneAddress(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Electronic RecordsPlease specify media type:Secure EmailFaxEmail or Fax Paper RecordsPlease specify media type:MailIn-Person Pick-Up (BIHC only)Address (if different from above) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code 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 test results.DO NOT release my sensitive information Purpose for ReleaseContinuing CareInsuranceLegalOtherOther (specify) This authorization is for the listed date(s) of treatment: MM slash DD slash YYYY From(If unknown, leave blank) MM slash DD slash YYYY ToInformation 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 report Operative Reports Discharge Summary Pathology Reports Laboratory Results Radiology Reports Cardiology Reports Other (specify) Redisclosure I understand that my health care 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 me 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 from the date of the consent, unless revoked by the patient’s authorized representative prior to that time.Name of Legal Representative Relationship Date MM slash DD slash YYYY
