UAMS Adult Psychiatry Clinic (APC) Date of Birth: ______________
Phone: (501)
686-5900
Purpose of access or
release: *
Continuity of care * Legal *
Educational * Medical *
Reimbursement * Patient
Request * Other _______________
I, ________________________________ authorize the APC to:
*
Release information to: *
Obtain information from:
__________________________________________________________
(Agency/Individual)
__________________________________________________________
(Address)
__________________________________________________________
_________________________________________________________
(Phone)
The specific information to be requested
or released:
* Discharge/Treatment Summary * Psychiatric/Medical Evaluation * Dates of Treatment
* Diagnostic Evaluation
* Lab/Other Diagnostic Records * Social History
*
Medical/Physical History * Progress Notes
* Treatment Plan
* School Observations
* Medication
Sheets * Psychological Evaluation /Testing
* Patient Demographics/ Insurance information * Alcohol/Drug
Abuse
* Other:__________________________________________________________
A
photocopy or faxed copy of this signed authorization shall constitute a valid
authorization. I certify that this
authorization has been given voluntarily and without coercion. I understand that I may revoke this
authorization at any time by giving written notice to the Adult Psychiatry
Clinic (“APC”), except to the extent that action has been by APC in reliance
upon this authorization. I understand
that the APC will not condition treatment, payment, enrollment or eligibility
for treatment on my signing of this authorization.
The APC, its faculty and
staff are released from legal responsibility or liability for the release of
the above information to the extent indicated and authorized herein.
This consent will automatically expire 60 days
after the date of the signature or 60 days after formal discharge from clinic,
whichever is later, unless I express written revocation at an earlier
date. I have read or
been informed that all blanks are properly filled in prior to my signature.
I understand that once the
above information is disclosed, it may be re-disclosed by the designated
recipient and the information may no longer be protected by federal privacy
laws and regulations.
I understand that the APC may charge
a reasonable, cost-based fee for copies of medical records that includes the
cost of copying, cost of supplies, labor of copying, and postage, if
applicable. APC will not charge more than is allowed by law.
_____________________________________________________ ____________________
Signature
of patient
Date
_________________________________________________________________
_________________________
Signature
of parent/guardian (if applicable)
Date
_____________________________________________________ ____________________
Signature
of witness
Date
_________________________________________________________________
____________________
Signature
of 2nd witness (when verbal consent is obtained) Date
_________________________________________________________________ _____________________
Program
Director’s Signature (required for alcohol/drug abuse information) Date
UAMS Administrative Guide Policy #3.1.28 Use and
Disclosure of PHI and Medical Records Policy