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Washington County Hospital and Clinics

Authorization of Release of Information

* Patient's Legal Name
* DOB (mm/dd/yyyy)
* MR#
Please list a person or Institution you are allowing to release medical information concerning the above named patient to the person or facility listed below. I would like this information to be shared by:
Paper Copies

(Please note burning to a CD is only possible when transferring electronic information. Copies of paper documents will be provided on paper only.)
  Name of Person and/or Institution who will receive information.
* Complete Mailing Address
Street, P.O. Box
* City
* State
* Zip Code
* Phone Number
in case we need to contact you for a question regarding form
  Specific description of information (including date(s) of service:
  Please check the reason for the release below: Insurance
Personal Use (patient only)
Continuing Medical Care
Worker's Compensation
Transferring Care

This authorization is voluntary. If I choose to cancel this authorization at a later date, I must send a written notification to the Director of Health Information Management, Washington County Hospital and Clinics, 400 E. Polk, P. O. Box 909, Washington, IA 52353. If this authorization is cancelled, I understand that information may have been released prior to the cancellation, and that action would not be considered a breach of confidentiality.
  I understand that the information may be released and may not include information in the following categories unless I specifically authorize the release (Mark any category to be released). Substance abuse
Mental Health
HIV-related information
  I have read and understand these conditions
* Patient or Patient's Authorized Representative
* Relationship of Authorized Representative
* Date (mm/dd/yyyy)
Prohibition of Redisclosure
This form does not authorize the release of medical information beyond the limits of this authorization. Where information has been disclosed from a record protected by federal law for alcohol/drug abuse records or by state law for mental health records, and HIV/AIDS test results, federal requirements (42 C.F.R. Part 2) and state requirements (Iowa Code ch. 228 & ch. 141) prohibit further disclosure without the specific written authorization of the patient, or as otherwise permitted by such law and/or regulations. A general authorization for release of medical or other information is not sufficient for these purposes. Civil and/or criminal penalties may result from unauthorized disclosure of alcohol/drug abuse or mental health related information or HIV/AIDS test results.