Idaho Medical Records Release Form

Authorization to Obtain or Disclose My Health Care Information

Documents

PDF icon Idaho Medical Records Release Form (436 KB)
Date of Birth:
Date Records Needed by:
Please check one:
I request and authorize to *
You may use or disclose the following health care information: *
Check all That apply.
I understand that my medical record may include information on the diagnosis/treatment related to psychiatric , psychological or mental conditions, drug or alcohol use or abuse, sexually transmitted disease (STD), acquired immune deficiency syndrome (AIDS), and HIV status and genetic testing. I consent for the following information to be disclosed: (initial by any/all that apply):
Medical records may include
Reason for authorization: *
If the reason for Authorization is for something other than the request of the individual, please let us know in the space provided
If date is not specified, this request will expire in 90 days from the date of signature. If the release id for the patient's EMPLOYER or FINANCIAL INSTITUTION for reasons other than payment, this authorization will remain valid for only 90 days. Patient may revoke this authorization at any time prior to expiration by notifying in writing.
Consent
The information disclosed pursuant to this authorization may be subject to redisclosure and no longer protected by federal law. State and federal law specifically requires that any patient medical record and/or personal health care information containing drug and alcohol diagnosis and treatment, mental health and sexually transmitted diseases, including HIV/AIDS are privileged and confidential and may only be disclosed by express authorization, except as require d by law. I understand that my alcohol and/or drug treatment records are protected under the Federal regulations governing Confidentiality and Drug abuse Patient Records, 42 CFR Part 2 and Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), 45 CFR pts 160 & 164, and cannot be disclosed without my written consent unless otherwise provided for by the regulations.
I understand that I may refuse to sign this authorization. The releasor or releasee may not condition treatment, payment, enrollment or eligibility on the authorization of this release.
Date:
Minor's signature
A minor’s signature alone is sufficient to release health care information related to (1) sexually transmitted diseases, including HIV/AIDS (age 14+), (2) alcohol and/or drug abuse (age 13+ (Idaho is 16+)), (3) mental health information (age 13+ (Idaho is 14+)), (4) birth control services ( WA only), (5) abortion services (WA only), and (6) prenatal care services (WA only).
Date of Minor Patient
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