AUTHORIZATION TO RELEASE AND DISCLOSE PATIENT INFORMATION

AUTHORIZATION TO RELEASE AND DISCLOSE PATIENT INFORMATION
Patient Information
Patient Name*

First NameLast Name
Patient Date of Birth*

MonthDayYear
Date
Patient Phone Number*
Please enter a valid phone number.
Patient Email
example@example.com
Please select request type*

I am requesting CHEMED to send my medical/dental records to another medical practice/provider (transfer out).I would like CHEMED to request my medical records from another medical practice/provider (transfer in).I am requesting CHEMED to send my medical/dental records to me (patient).

Patient Rights & Signature
- I understand that I may revoke this authorization at any time by submitting a written request to CHEMED, except to the extent that action has already been taken in reliance on it.
- I understand that information disclosed based on this authorization may be subject to re-disclosure by the recipient and no longer protected by HIPAA.
- SUD information/records cannot be further disclosed by the person or entity named above without further authorization because 42 CFR Part 2 prohibited unauthorized disclosure of these records. (42 CFR 2.32)
- HIV/AIDS related information cannot be further disclosed by the person or entity named above without written consent/authorization of the individual in accordance with N.J.S.A. 25:5C-8, 26:5C-11.
- I understand that signing this authorization is voluntary. My treatment, payment, enrollment in a health plan, or eligibility for benefits will not be conditioned upon my authorization of this disclosure.
Signed by (signature of individual or legal guardian/legal representative)*

Clear
Name of individual or legal guardian/legal representative*
Relationship to individual/legal authority*
Sign date:*

MonthDayYear
Date
Patient Signature (for patients 14-18 years of age):

Clear
Sign date:

MonthDayYear
Date
Our address for sending documents:

1771 Madison Ave, Lakewood, NJ 08701

Click here to send via our secure portal

Tel: 732-364-2144

Fax: 732-364-3559
Email
example@example.com
Should be Empty:

Patient Information