Free Nursing Home Health Information Disclosure Authorization Form Template
Nursing Home Health Information Disclosure Authorization Form
This Nursing Home Health Information Disclosure Authorization Form is provided to facilitate the sharing of pertinent health information between [Your Company Name] and authorized individuals or entities involved in the care of our residents. Please carefully review and complete the following sections to ensure the proper disclosure of health information in accordance with applicable laws and regulations.
Patient Information
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Name: |
[Patient Name] |
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Date of Birth: |
[Date of Birth] |
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Address: |
[Patient Address] |
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Phone Number: |
[Patient Number] |
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Email Address: |
[Patient Email] |
Authorization Details
I, the undersigned, hereby authorize [Your Company Name] Nursing Home to disclose my health information as described below:
1. Information to be Disclosed
Please check the boxes to indicate the types of health information you authorize to be disclosed:
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Medical History
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Medication Records
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Treatment Plans
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Lab Results
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Diagnostic Reports
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Progress Notes
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Discharge Summaries
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Other (please specify):
2. Purpose of Disclosure
Please describe the purpose for which the health information will be disclosed:
3. Expiration Date
This authorization shall expire on [Expiration Date] unless otherwise specified.
Patient/Legal Representative Signature:
I understand that I have the right to revoke this authorization at any time, except to the extent that action has been taken in reliance on it, by providing written notice to [Your Company Name].
[Date]
Witness Signature (if applicable):
[Witness Name]
[Date]
[Your Company Name] Nursing Home reserves the right to refuse any request for disclosure that does not comply with applicable laws and regulations.
