RELEASE OF RECORDS (Leaving Health Center)

Lowell Community Health Center Health Information 161 Jackson Street, 2nd Floor Lowell, MA 01852 978.322.8680 (phone) I 978.446.9830 (fax) health_Information@lchealth.org (email)

AUTHORIZATION FOR RELEASE OF HEALTH RECORDS

We are required by law to obtain your written permission to release your medical Information.

PATIENT NAME

DATE OF BIRTH

Date

ADDRESS

TELEPHONE

CITY STATE ZIP

SOCIAL SECURITY

1. I hereby authorize the release of the health records obtained in the course of my treatment at Lowell Community Health Center.

Name Of Facility

Address

City State Zip

For the time period

Reason for release

2 The specific Information to be released is

CFR-42 Confidential patient records

If my Initials appear here----- I specifically authorize release of drug, alcohol abuse, sexually transmitted disease and/or counseling/psychiatric records. I understand that my drug treatment records are protected by under federal regulations governing Confidentiality of Alcohol and Drug Abuse Patient Records, 42 C.F.R. Part 2, Subpart C and cannot be disclosed without my written consent unless otherwise provided for in the regulations.

HIV/Aids/STI

If my Initials appear here----- I specifically authorize release of my records that contain Information aboutmy HIV diagnosis, tests or treatment of HIV and AIDS, and which may contain reference to my Identity as HIV positive or as an AIDS patient.

I specifically authorize release of drug, alcohol abuse, sexually transmitted 3. If my Initials appear here, disease and/or counseling/psychiatric records. | understand that my drug treatment records are protected by under federal regulations governing Confidentiality of Alcohol and Drug Abuse Patient Records, 42 C.F.R. Part 2, Subpart C and cannot be disclosed without my written consent unless otherwise provided for in the regulations. 4. If my Initials appear here my HIV diagnosis, tests or treatment of HIV and AIDS, and which may contain reference to my Identity as HIV positive or as an AIDS patient. 5. I have carefully read and understand the above statements, and do herein expressly and voluntarily consent to disclosure of the above Information about, or health records of my condition to those persons of agencies named above.

I specifically authorize release of my records that contain Information about

6. I understand this authorization is subject to revocation at any time. Except to the extent that disclosure made in good faith has already occurred. Revocation must be made in writing. This authorization will expire1 year from the date shown below.

7. Information released may be subject to re-disclosure by recipient.

Health Record Number

Date

Signature of patient or representative

Authority or relationship of representative

Date

Witness

Please note that there may be a fee for reproducing copies of health records.

HEALTH CENTER