OCHSNER CLINIC FOUNDATION HEALTH INFORMATION

OCHSNER CLINIC FOUNDATION

HEALTH INFORMATION MANAGEMENT

RELEASE OF INFORMATION

According to the new HIPAA (Health Insurance Portability and Accountability Act) Regulations, enclosed

you will find a form that must be filled out by the patient.

All aspects of the form must be filled out COMPLETELY.

To be valid, the Authorization must be properly filled out, dated and signed by the patient. The

Authorization will terminate on the date indicated on the Authorization or when revoked in writing by the

patient. If the patient is deceased and did not expire at this facility, and you are the next of kin, please

include a copy of the death certificate.

Due to the volume of requests for copies of medical records received daily, Ochsner Health System

contracts MRO (Medical Records Online) to copy and release the medical records. For this service, there is

a fee mandated by law, however, medical information will be forwarded to hospitals and physicians free of

charge.

Service Charge:

Paper Electronic Delivery (CD/EMAIL)

$0.20 per page $0.20 up to $100 (Max amount charged)

Plus, tax and postage

Please mail your authorization form to us at:

Ochsner Medical Center and Health Center Baton Rouge

Attn: Release of Information

17000 Medical Center Dr.

Baton Rouge, LA 70816

If you have any questions regarding the release of your medical information, please contact the Release of

Information Department (225) 236-5917 or (225) 755-4803.

If you are a patient and would like to submit your authorization via fax, you may fax to the Release of

Information (225) 236-5469 or (225) 761-5939

I have read and agree with the explanation of charges.

__________________________________________________________________________

___________________________________

Signature of patient or authorized representative Date

(Revised 07/17/14)

AUTHORIZATION FOR RELEASE OF

CONFIDENTIAL INFORMATION

, authorize the release of alcohol and/or drug abuse treatment and information.

(Patient's Signature)

, authorize the release of HIV test results and/or HIV treatment information.

(Patient's Signature)

, authorize the release of psychiatric information.

(Patient's Signature)

Address

to release information specified below from my

NAME OF HOSPITAL / PHYSICIAN / FACILITY

, hereby authorize

FULL NAME OF PATIENT

Patient's Name Date of Birth

medical records covering the dates of service to

The information which is checked (X) below is to be released to:

NAME OF HOSPITAL, PHYSICIAN, SERVICE AGENCY OR THIRD PARTY

ADDRESS CITY STATE ZIP

Purpose for Release: Medical Insurance Legal Other

Check off items being released:

Discharge Summary

History & Physical

Consultation Reports

Pathology Reports

Laboratory

Dictated Letter

Other ___________________________

Hospital admission

Clinic Visit

Cardiology

Abstract ( )

The patient's express authorization is required to r

elease certain types of records, including alcohol and/or drug abuse treatment

and information, HIV testing and treatment, psychiatric treatment, and genetic testing (defined 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:

Entire Record

ER Record

X-ray Report

Operative Report

ADDRESS DATE SIGNED

SIGNATURE OF PATIENT OR AUTHORIZED REPRESENTATIVE RELATIONSHIP TO PATIENT

CORRESPONDENCE

In authorizing the release of the confidential infor

mation identified above, I hereby waive all restrictions or privileges imposed by

law and release Ochsner Medical Center and Ochsner Health Centers and its staff 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 to re-disclosure by the recipient and may no longer be protected. I understand

that my treatment, payment, enrollment or eligibility for benefits may not be conditioned on signing this authorization.

If expiration date is left blank, authorization will

expire within one year.

This authorization may be revoked in writing at any time, except to the extent that Ochsner Medical Center and Ochsner

Health Centers have already taken action in reliance on it. Letters to revoke this authorization should be addressed to

Ochsner Medical Center-Baton Rouge, Release of Information Department, 17000 Medical Center Drive, Baton Rouge, LA 70816

If not previously revoked in writing, this authorization will terminate

or expire upon (state the specific date, event, or condition):

Form No. 20410-BR (Rev. 7/16/2014)

Method of Delivery: paper Electronic delivery: Email address _________________________________________

Ochsner Medical Center - Baton Rouge

17000 Medical Center Drive

Baton Rouge, LA 70816

Phone #

Discharge Instructions/After Visit Summary

, authorize the release of genetic testing information.

(Patient's Signature)

PHONE NUMBER

Fax: (225) 236-5469 or

(225) 761-5939

Phone: (225) 236-5917 or

(225) 755-4803