HIPAA Record Release

I. HIPPA COMPLIANCE
Legal First Name
Legal Last Name
Date of Birth

MonthDayYear
Date
You have the right to restrict how your protected health information is used and disclosed for treatment, payment or healthcare operations. We are not required to agree with this restriction, but if we do, we shall honor this agreement. The HIPAA (Health Insurance Portability and Accountability Act of 1996) law allows for the use of the information for treatment, payment, or healthcare operations.

By signing this form, you consent to our use and disclosure of your protected healthcare information to only you, your doctor, your insurance and the person(s) listed below. You have the right to revoke this consent, in writing, signed by you. However, such a revocation will not be retroactive.

I authorize the release of my protected health information, including records, results and images to the following person(s):
(Please check all that apply and indicate names of party authorized)
Spouse
Children
Other
MESSAGES OR APPOINTMENT REMINDERS
Messages will be of a non-sensitive nature, such as appointment reminders.
I authorize UDI to leave messages at provided home / cell using practice name.
I authorize UDI to text or email my provided contact.
II. OUTSIDE IMAGES/RECORDS RELEASE
UDI is committed to providing you and your physician quality care. If you have had relevant imaging done, please complete this portion of the form. Our Radiologists aim to provide a comprehensive analysis for your condition. Please list ALL related prior Imaging Facilities.

ONLY complete the below "Prior Images/Records" portion below if applicable.
PRIOR IMAGES/RECORDS
Name of the Facility or Hospital where your prior scans were performed
Type of Body Part Films
Date of Service
I have read and understand the terms of the I. HIPAA and II. Record Release

(if applicable)sections above.
PATIENTPARENTLEGAL REPRESENTATIVES SIGNATURE

Clear
DATE

MonthDayYear
Date
sysAccountName
sysAppointmentID
sysOrderID
sysPatientID
sysCareflowPrefillID
userrole
sysUserName
sysReportOutputTemplates
Should be Empty:

I. HIPPA COMPLIANCE

MESSAGES OR APPOINTMENT REMINDERS

II. OUTSIDE IMAGES/RECORDS RELEASE

PRIOR IMAGES/RECORDS