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Authorization to Release Patient Information

This electronic form may be used by a patient or legal representative to authorize the release of information to a third party such as an insurance company, employer, or for legal purposes, etc. 

Patient full name  *Maiden name Street  *City  *State  *Date of birth  *Phone number  *Social security number (last four digits only)  *

I hereby authorize the use or disclosure of protected health information about the above individual as described below.

1. The protected health information to be DISCLOSED from or used by Blanchard Valley Health System. 

2. Person/Physician/Organization authorized to RECEIVE or use the information:

Check below if the person receiving this information is the patient, then you do not need to complete the address and phone a second time. Proceed to question number three. 

Recipient name: Address (include street, city, state and zip code) Phone number: Fax number: 

3. The purpose of the authorized use or disclosure of the information is as follows:

Check all that apply 

Please specify OTHER: If you selected MARKETING in #3, please indicate whether Blanchard Valley Health System will receive any remuneration or payment from a third party as a result of the marketing: 4. Date of service to be disclosed or used FROM:  *Date of service to be disclosed or used TO:  *5. Records to be disclosed or used: 

Please specify OTHER: ** According to Blanchard Valley Health System Notice of Privacy Practices and Designated Record Set 6. I understand that the information in my medical record may include information relating to sexually transmitted disease, acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV). It may also include information about behavioral or mental health services and treatment for alcohol and drug abuse. I understand that by signing this authorization I am authorizing the release of such information unless specified otherwise above. 7. I understand that if the person or entity that receives the above information is a not a health care provider or health plan covered by federal privacy regulations, the information described above may be redisclosed by such person or entity and will likely no longer be protected by the federal privacy regulations. 8. As described in the Notice of Privacy Practices of Blanchard Valley Health System, I understand that I may revoke this authorization in writing at any time by sending a written revocation to BVHS Privacy Officer, 1900 South Main Street, Findlay, OH 45840. I understand the revocation will not apply to information that has already been released in response to the authorization. 9. This authorization will remain valid for one year from today’s date or: 

Select date if you checked the above box: If you selected the authorization should end at the end of the research study, this is applicable only if the authorization is for a research study or for creation and maintenance of a research database or research repository. 10. I understand that I am not required to sign this authorization form and that BVHS will not condition the provision of treatment or payment to me on the signing of this authorization, except that BVHS may condition the provision of research-related treatment to me on the signing of this authorization for the use or disclosure of my personal health information for such research. BVHS may also condition the provision of health care to me that is solely for the purpose of creating protected health information for disclosure to a third party on the signing of this authorization. 11. The information requested should be disclosed: 

Secure email to: I will pick up the requested documents at Blanchard Valley Hospital. Please provide in the following format: 

Electronic signature of patient or legal representative  *

Complete this final section if you are NOT the patient. If you are the patient, proceed to "SUBMIT"

If you are the legal representative of the patient, describe the scope of your authority. 

Upload documentation supporting your legal representation of the patient