Authorization for Use and Disclosure of Protected Health Information

Patient Identication:

Printed Name: ________________________________________________ Date of Birth: _______________________________________

Complete Address: _________________________________________________________________________________________________

Social Security #: ______________________________________________ Telephone:(______) _________________________________

Information to be Released – Covering the Periods of Health Care

From (date) _________________________________________ to (date) __________________________________________

Please check type of information to be released:

 Complete health record Diagnosis and treatment codes  Discharge summary

 Treatment or consultation At the request of the patient  Billing or claims payment

(Indicate which applies) Send To / Obtain Information From:

Paper CD Electronic Portal Email

Release to Name: ______________________________________________ Email: ____________________________________________

Name: _____________________________________________________________________ Phone #: ____________________________

Address: ___________________________________________________________________ Fax #: ______________________________

Drug and/or Alcohol Abuse, and/or Psychiatric, and/or HIV/AIDS Records Release

The patient’s express authorization is required to release certain types of records, including alcohol and/or drug abuse treatment and information, HIV

testing and treatment, psychiatric treatment, and genetic testing (dened in the Genetic Information Non-Discrimination Act of 2008 - GINA, section 201

7 A and B). To authorize release of this information, please read and sign the following:

(Patient’s Signature)

I, _______________________________________________________ authorize the release of genetic testing information.

(Patient’s Signature)

Time Limit and Right to Revoke Authorization

Except to the extent that action has already been taken in reliance on this authorization, at any time I can revoke this authorization by submitting

a notice in writing to Ochsner LSU Health Shreveport, 1541 Kings Highway, Shreveport, LA 71103, Health Information Management Department.

Unless revoked, this authorization will expire on the following date or event____________________or 180 days from the date of signature.

In authorizing the release of the condential information identied above, I hereby waive all restrictions or privileges imposed by law and release

Ochsner LSU Health Shreveport and its aliates and their sta from any restriction or privilege imposed by law in connection with the disclosure

or release of any professional record, observation or communication. I do understand that the information that is being released may be subject

1541 Kings Highway • Shreveport, LA 71103 • Phone: 318-626-2069 • Fax: 318-698-4294