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Patient Demographics
   
  New Patient Medical Information
   
  Authorization for Disclosure
  (Release of Medical Records)
  Revocation of Authorization
  (Revoke of Medical Records)    
Authorization for the Use or Disclosure of Protected Health Information
SOUTHEASTERN CARDIOVASCULAR CONSULTANTS
7777 HENNESSY BOULEVARD
SUITE 8000
BATON ROUGE, LOUISIANA 70808
Phone: (225) 767-1151 Fax: (225) 769-7348
As required by the Health Insurance Portability and Accountability Act of 1996, SCVC may not use or disclose your health information except as provided in our Notice of Privacy Practices without your authorization. Your signature on this form indicates that you are giving permission for the uses and disclosures of protected health information described herein. You may revoke this authorization at any time by signing and dating “A Revocation of Authorization to Release Protected Health Information” form which can be obtained from this office.
Patient Name:
* Last Name
* First Name
Middle Name
DOB: Social Security #: Chart # :

* / /

* - -

 
From (Individual/Facility):
*
Practitioner:
*
Address:
*
City State Zip
* * *
 
Phone: Fax:
* ( ) -
( ) -
To (Facility/Doctor’s Office):
*
Practitioner:
*
Address:
*
City State Zip
* * *
 
Phone: Fax:
* ( ) -
( ) -
 
I, * (type name) hereby authorize the use and disclosure of the following health information that pertains to me for the following treatment dates from* / / to * / / .
 
Office visit notes Test results Entire Chart
Laboratory Results Copies of EKG’s Other Specify
Hospital Procedure Reports Hospital visit notes
 
 
I understand that certain information cannot be released without specific authorization as required by state or federal law. By initialing the lines below, I authorize the release of the following protected or sensitive information:

Information regarding the patient’s diagnosis and treatment for HIV/AIDS
Psychotherapy notes
Treatment for alcohol or drug abuse
 
For the following purposes: Medical Legal Insurance Personal Other
 
This authorization shall be in force and effect from * / / until * / / at which time this authorization to use or disclose this protected health information expires.
 
I understand and consent to all of the following:
• This authorization will automatically expire on / / . If not expiration date is specified here, this authorization will expire six (6) months from the date on which it was signed.
 
• I am under no obligation to sign this authorization. I further understand that my ability to obtain treatment, my eligibility for benefits, etc. will not depend in any way on whether I sign this authorization or not.
 
• The released information may contain alcohol and drub abuse, psychiatric, HIV or genetic information.
• I have a right to inspect and to obtain a copy of any information disclosed pursuant to this authorization. SCVC is entitled to receive compensation in accordance with the laws of the State of Louisiana relative to the release of medical records.
 
 
 
Enter the code as it is shown:
 
This field helps prevent automated access.
 
 
Date * / /
 
 
 
 
 
   
 
 
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