Authorization for Release of Information to Disclose and Receive

Authorization for Release of Information to Disclose and Receive
Name (Nombre)*

First Name (Primer Nombre)Middle Name (Segundo Nombre)Last Name (Apellido)
Date of birth (Fecha de nacimiento)*

MonthDayYear
Address (Direccion)*

Street Address (Direccion)

Street Address Line 2

CityState / Province

Postal / Zip Code
City, State, Zip Code (Ciudad, Estado, Codigo Postal)*
Phone Number (Numero de teléfono)*

Street Address

Street Address Line 2

City

Postal / Zip Code
E-mail address (Dirección de correo electrónico)

Street Address

Street Address Line 2

City

Postal / Zip Code
Please select one of the two options below. Would you like to have information released from NFP or released to NFP? If you make a selection and then need to change it, you will need to start the form again.
I authorize information be obtained FROM (Enviar de)

Neighborhood Family Practice 3569 Ridge Road Cleveland, OH 44102 Phone: 216-281-0872 Fax: 216-281-9721
I authorize information be released TO (Enviar a)

Outside facility/person - Complete fields below
Name of facility/person*
Name of facility/person
Address (Direccion)*

Street Address (Direccion)

Street Address Line 2

CityState / Province

Postal / Zip Code
City, State, Zip Code (Ciudad, Estado, Código Postal)*
Phone Number (Numero de teléfono)*
Fax Number (Numero de fax)*
I authorize information be obtained FROM (Enviar de)

Outside facility/person - Complete fields below
Name of facility/person*
Name of outside facility/person
Address (Direccion)*

Street Address (Direccion)

Street Address Line 2

CityState / Province

Postal / Zip Code
City, State, Zip Code (Ciudad, Estado, Código Postal)*
Phone Number (Numero de teléfono)*
Fax Number (Numero de fax)*
I authorize information be sent TO (Enviar a):

Neighborhood Family Practice (Select a location below)Ridge - 3569 Ridge Rd., Cleveland, OH 44102 Fax 216-281-9721Tremont - 2358 Professor Ave., Cleveland, OH 44113 - Fax 216-589-0017Detroit Shoreway - 6412 Franklin Blvd., Cleveland, OH 44102 - Fax 216-961-9580Puritas - 14625 Puritas Ave., Cleveland, OH 44135 - Fax 216-252-4600W 117 - 11709 Lorain Ave., Cleveland, OH 44111 - Fax 216-251-8900North Coast - 11906 Madison, Lakewood, OH 44107 - Fax 216-529-5051Ann B Reichsman - 3545 Ridge Rd., Cleveland, OH 44102 - Fax 216-250-3821
Purpose for disclosure (Proposito de la divulgación) Select (Select all that apply (Seleccione todas las que correspondan)*

DisabilityLegalNew ProviderPersonalOther
Description of information to be released (Descripción de la información que se publicara)*

Office VisitsBehavioral Health VisitsRadiology ReportsLaboratory ResultsDental RecordsOther
(From) Date range for records to be released (Intervalo de fechas para que se publiquen los registros) (De)*
(To) Date range for records to be released (Intervalo de fechas para que se publiquen los registros (A)*
I, the undersigned, authorize Neighborhood Family Practice to release health information as indicated/described above. I understand and acknowledge that the requested health information may contain information regarding physical and mental illness, HIV test results or diagnosis, treatment of AIDS/AIDS-related conditions, sexually transmitted disease and/or alcohol/drug abuse. You may request for this information not to be released through written notice presented to Neighborhood Family Practice Medical Records Department at 3569 Ridge Road Cleveland, OH 44102
This authorization will expire one year from the date of authorization written below, unless revoked by me or my legal representative. I understand that I, (or my legal representative), have the right to revoke this authorization at any time, which I may do through written notice presented to Neighborhood Family Practice Medical Records Department 3569 Ridge Road Cleveland, OH 44102. I understand that the revocation will not apply to my insurance company when the law provides my insurer with the right to contest a claim under my policy or to information that has already been released in response to this authorization. I understand that authorizing the disclosure of this health information is voluntary. I understand that treatment, payment, enrollment, or eligibility for benefits will not be based on whether or not I sign this authorization. Access to medical information is the right of every patient, however I understand that I may be charged for copies according to Ohio Revised Codes: 3701.74, 3701.741 and 3701.742. After my health information is released, my information may be re-disclosed by the recipient and may no longer be protected by law. If I have questions about disclosure of my health information, I can contact the Privacy Officer or other individual at the organization identified above
Yo, el abajo firmante, autorizo a Neighborhood Family Practice a divulgar mi información de salud como se indica/describe en la parte de arriba. Comprendo y reconozco que la información de salud solicitada puede contener información relacionada con enfermedades físicas y mentales, resultados de pruebas de VIH o diagnóstico, tratamiento de SIDA/ enfermedades relacionadas con el SIDA, enfermedades de transmisión sexual y / o abuso de alcohol o drogas. Usted puede solicitar que esta información no sea enviada a través de un aviso por escrito presentado al Departamento de Registros Médicos de Neighborhood Family Practice en 3569 Ridge Road Cleveland, OH 44102

Esta autorización expirará un año a partir de la fecha de autorización escrita abajo, a menos que sea revocada por mí o mi representante legal. Entiendo que yo, (o mi representante legal), tengo el derecho de revocar esta autorización en cualquier momento, lo cual puedo hacer por notificación escrita presentada al Departamento de Registros Médicos de Neighborhood Family Practice 3569 Ridge Road Cleveland, OH 44102. Entiendo que la revocación no aplicará a mi compañía de seguros cuando la ley otorgue a mi aseguradora el derecho de impugnar una reclamación bajo mi póliza o información que ya ha sido liberada en respuesta a esta autorización. Entiendo que autorizar la divulgación de esta información de salud es voluntaria. Entiendo que el tratamiento, pago, inscripción o elegibilidad para beneficios no se basará en si firmo o no esta autorización. El acceso a la información médica es el derecho de cada paciente, sin embargo, entiendo que se me pueden cobrar copias de acuerdo con los Códigos Revisados de Ohio: 3701.74, 3701.741 y 3701.742. Después de que se publique mi información de salud, mi información puede ser re-divulgada por el receptor y puede que ya no esté protegida por la ley. Si tengo preguntas sobre la divulgación de mi información de salud, puedo contactar al Oficial de Privacidad u otro individuo en la organización identificada anteriormente.
Patient's signature / Patient's Legal Represenative (Firma del paciente / Representante legal del paciente)*

Clear
Today's Date (Fecha de hoy)*

MonthDayYear
Today's Date
Printed Name (Nombre en letra de imprenta)*
Relationship, if not the patient (required, if legal representative) (Relación, si no es el paciente) (requerido, si es representante legal)
Should be Empty: