Columbia Medical Practice

Patient Name __________________________________ SS# ______________________

Address __________________________________________________________________

City _______________________________________ State _______ Zip ____________

Phone ____________________ Date of Birth ___/___/_____

I hereby authorize Name: ___________________________________________________

Address __________________________________________________________________

_________________________________________________________________________

to release:

	Office notes, outside reports, consults		Radiology reports
	Lab reports		Problem list
	Cardic tests		Misc.

I understand that:

This authorization gives my special permission to release any PHI that is contained in my medical record unless I specifically indicate "NO" next to one or more of the categories noted below:

____Substance Abuse Information ____Psychiatric/Mental Information ____HIV Information
This authorization is voluntary and being made at the request of the individual.
The released PHI may no longer be protected by Federal Privacy Laws and may be re-disclosed by the individual or organization authorized to receive the PHI.
This authorization will not be used for medical underwriting; therefore, my treatment, payments, enrollment or eligibility for benefits will not be conditioned on my signing this authorization.
This authorization will automatically expire one year from the date signed.
I may revoke this authorization at any time except to the extent that action has been taken in reliance thereon.

Signed ______________________________________________ Date ______________

(If not patient, state relationship)

Witness _____________________________________________ Date ______________