Authorization to Release and Disclose Medical Information

Authorization to Release and Disclose Medical Information
Patient Name*

First NameLast Name
Patient Date of Birth*

MonthDayYear
Date
Patient Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Patient Email
example@example.com
Please select request type*

I am authorizing CHEMED to send my records to another medical practice/provider (transfer out).I am authorizing CHEMED to request my records from another medical practice/provider (transfer in).I am requesting CHEMED to send my medical records to me (patient).I am giving consent for CHEMED to verbally disclose my information to another individual/practice/provider.

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.
Patient (or Legal Representative) Signature*

Clear
Print name*
*

I am the patientThe patient is someone whom I have the authority to sign this authorization for
Enter your relationship with the patient/legal authority over the patient
Date of signature*

MonthDayYear
Date
**Patients between the ages of 14-17 are required to sign this authorization as well: Patient should sign in the box below:

Clear
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
Should be Empty:

Authorization to Release and Disclose Medical Information

Information to be released

Patient Rights & Signature