Patient Forms 2

Release of Protected Health Information

Patient Name*

DOB*

Address*

City*

State*

Zip code*

Phone*

I, the patient named above or his/her/them parent/legal representative, hereby authorize TeleMed2U to release/obtain information regarding my medical history, illness or injury, consultation, prescriptions, treatment, diagnosis, or prognosis, including X-rays, correspondence and/or medical records including those from my other health care by means of mail, fax, or other electronic methods from/to:

Name of Entity/Person*

Address*

City*

State*

Zip code*

Phone*

Fax*

My health information as described below. I understand that this authorization extends to all or any part of the records, which may include treatment for physical and mental illness (except for psychotherapy notes), chemical or alcohol dependency, communicable disease such as Human Immunodeficiency Virus (“HIV”) and Acquired Immune Deficiency Syndrome (“AIDS”) test results or diagnoses. I understand that my records may be protected by the Federal Rules for Privacy of Individually Identifiable Health Information (Title 45 of the Code of Federal Regulations, Parts 160 and 164), the Federal Rules for Confidentiality of Alcohol and Drug Abuse Patient Records (Title 42 of the Code of Federal Regulations, Chapter 1, Part 2), and/or state laws, and cannot be disclosed without my written consent at any time. I understand this consent is subject to revocation at any time, except to the extent that action has been taken in reliance on it, and that in any event this consent expires automatically as indicated below. I understand that this authorization is voluntary, and I may refuse to sign this authorization. I further understand that my health care and payment of my health care will not be affected if I do not sign this form.

All Records

Progress Notes

Psychiatric Evaluation

Psychological Testing

Lab Tests/Medical
Imaging

Medication
Information

Alcohol/Drug Abuse
(43 CFR Part 2)

Other

I understand that if the recipient authorized to receive the information is not a health plan or health care provider, the released information may no longer be protected by federal and state privacy regulations. I understand that this authorization will expire 365 days from the date of this authorization unless I otherwise specify. I desire this authorization to be in effect untilPermissions for further use or disclosure of this medical information is not granted unless another authorization is obtained from me or unless such disclosure is specifically required or permitted by law.
A photocopy of facsimile of this authorization shall be considered as effective and valid as the original.
A have been advised of my right to receive a copy of this authorization.
I hereby release TeleMed2U from all legal responsibilities or liability that may arise from disclosure of my medical records in reliance of this Authorization.

Signature of patients or legal/personal representative*

Relationship if other than patient

Patient’s Name (Print)*

Date*

Patient’s Date of Birth *

Phone No*

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Patient Forms 2

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