Spectra Health Medical ROI

Authorization for Disclosure of Protected Health Information

Medical Records
Patient Information
Patient Name

First NameLast Name
Patient Date of Birth

MonthDayYear
Date
Patient Address

Street Address, Unit/Apt

Street Address Line 2

CityState

Zip Code
Maiden/Other Names Used
Patient Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Patient Email
example@example.com
Disclosure Details

Please complete the following fields with the third party's information and how you would like Spectra Health to interact with them.
This authorization form allows Spectra Health to
NOTICE:

Authorization for Release requests marked as MUTUALLY EXCHANGE will be filed as such, but no immediate action will be taken to release records to or obtain records from the parties listed.

If immediate release of records is needed, please choose either "RELEASE" or "OBTAIN" above.
Name of Third Party (the entity the records should be released to or obtained from)
I understand that if the person(s) and/or organization(s) listed above are not health care providers, health plans, or health care clearinghouses, who must follow privacy standards, the health information disclosed as a result of the authorization may no longer be protected by the federal privacy standards and my health infomation my be redisclosed without obtaining my authorization.
Address

Street Address, Unit/Apt

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Fax Number
Please enter a valid fax number.Format: (000) 000-0000.
Information to be Disclosed (mark all applicable categories)

Other
Beginning of time period: Date* End of time period: Date*
SUBSTANCE USE DISORDER INFORMATION is protected under the federal regulations governing Confidentiality of Substance Use Disorder Patient Records, 42 C.F.R. Part 2, and cannot be disclosed without written consent unless otherwise provided for in the regulations. In accordance with North Dakota law, the signature of a minor 14 years of age or older is required to disclose substance use disorder information. Please acknowledge this statement by selecting the box below.
Purpose for Disclosure (mark all applicable categories)

Other
YOUR RIGHTS WITH RESPECT TO THIS AUTHORIZATION:

Right to Inspect or Copy the Health Information to be Used or Disclosed - I understand that I have the right to inspect or copy the health information I have authorized to be used or disclosed by this authorization form. I may arrange to inspect my health information or obtain copies of my health information by contacting Spectra Health Clinical Records Department at (701) 757-2810.

Right to Receive a Copy of this Authorization - I understand that if I agree to sign this authorization - of which I am not required - I must be provided with a signed copy of the form.

Right to Refuse to Sign this Authorization - I understand that I am under no obligation to sign this form and that the person(s) and/or organization(s) listed above who I am authorizing to use and/or disclose my information may not condition treatment, payment, enrollment in a health plan or eligibility for health care benefits on my decision to sign this authorization.

Right to Withdraw this Authorization - I understand written notification is necessary to cancel this authorization. To obtain information on how to withdraw my authorization or to receive a copy of my withdrawl, I may contact: Spectra Health Clinical Records Department at (701) 757-2810. I am aware that withdrawal will not be effective as to uses and/or disclosures of my health information that the person(s) and or organization(s) listed above have already made about this authorization.
Expiration Date

MonthDayYear
If an expiration date is not specified, this form will be valid for one year from the date of signature
Relationship to Patient
If signed by someone other than the patient, state relationship and ability to do so (e.g., parent, legal guardian, power of attorney, etc.), otherwise, state "self".
Signature

Clear
Today's Date

MonthDayYear
Date
Should be Empty:

Authorization for Disclosure of Protected Health Information

Patient Information

Disclosure Details