AUTHORIZATION FOR RELEASE OF INFORMATION
PART A: PATIENT INFORMATION
Patient Name: Phone:
Email:
Address:
Date of Birth: SS# (last 4 digits):
Medical Record #
:
PART B: PERSON OR COMPANY WHO WILL RECEIVE INFORMATION
Self
(
same
info as
above)
Person
or
Entity:
Phone:
Emai
l:
Address:
Fax:
PART C: INFORMATION TO BE RELEASED (check all that apply)
Records or Information:
Abstract/Summary
(Discharge Summary,
Operative/Procedure
Notes, Pathology,
Laboratory, ED Notes,
Clinic Visits, Consults)
Discharge Summary
History and Physical
Con
sultation Repor
t
Operative Report
Laboratory Reports
Pathology Reports
Ra
diology Reports
Ra
diology I
mage
s
Physical/Occupational Thera
py
Immunization Record
Eme
rgency Department Record
Cli
nic Visit
S
pecify Provider/Clinic
Other (please specify)
Entire Record
Billing Records
Treatment Location:
All Duke Health
Enterprise Entities
Duke University Hospital
Duke Raleigh Hospital
Duke Regional Hospital
Duke Clinic (specify provider / location)
Treatment Date(s):
From to (please be specific) All Treatment Dates
PART D: PURPOSE OF REQUEST
Personal Legal Insurance
Continuation of Care Other (specify):
PART E: FORMAT AND DELIVERY OF INFORMATION
Format ( select only one)
MyChart
CD
Encrypted Email
Thumb drive (flash drive)
Paper
Fax
Other
Oral Communication
Delivery Method (select only one)
Electronic (MyChart, encrypted email)
Mail
In-Person Pick up (Name:
PART F: REVIEW AND APPROVAL
I understand that the information to be released may include reference to sensitive information related to mental and behavioral
heal
th, genetic t
esting,
HIV/AIDS
or
other
communicable
diseases, and drug or
alcohol
abuse.
I
specifically a
pprove
the
release
of
the
following
information
that has b
een
marked as
sensitive
and/or
restricted
(check
all
that apply):
Mental
and Behavioral
Heal
th Substance
Use
Disorder
Gene
tic
Testing
_____
________________________
__________
__________________________
)
I understand that I may r evoke this Authorization in writing at any time, except to the extent that action has already been taken
in
response
to
the
Authorization.
I
understand
that the
information
disclosed pursuant to this
Authorization
may
be
subject to
re-disclosure
by th
e
recipient and may
no longer
be
protected
under
federal
privacy l
aw.
I understand that
I
may
refuse
to
sign
this
Authorization.
If
I
do
not sign
this Authorization, Duke
Health will
continue
to
provide
treatment
and seek
payment
for
services
provided.
Duke
Health
may c
harge
a
fee
for
providing
the
information
specified
above.
This
Authorization
will
a
utomatically
expire one year
from
the date
signed
below
unless
revoked
or
another
date or
event
is
written
here: .
_____________
Sign
ature
Printed
Name
___________________________________________________________________________________
Date
Witness
Signature
ID
# Date
PART
G:
REPRESEN
TATIVE (complete
if
signed b
y personal or authorized representative)
Representative Full Name (please print)
Relationship to Patient Phone Number
If you are not the patient or the parent of a minor patient, you MUST attach documentation of your authority to act on b ehalf
of the patient (Power of Attorney, Court Order, Legal Guardian Documentation, Executor/Administrator Documentation)
SEND COMPLETED FORM TO: ROI-requestor3@dm.duke.edu; Fax: 919-620-5165 OR
Duke University Hospital - HIM P.O. Box 3016 Durham, NC 27710; For Questions Call: 919-684-1700
Rev. 4/19
