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Div of Immigration Health Serv Auth for Release of Conf Info Form

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Division of Immigration Health Services
Authorization for Release of Confidential Health Information

I hereby authorize
Name/Address

to disclose health information from my medical records.
Detainee Name/A#:
DOB:

Country of Origin:

Covering the period(s) of healthcare from

to
Date

Information to be disclosed:
Complete Health Record
Progress Notes

Date

H&P Exam

Radiology Reports/EKGs

Lab Reports

Mental Health Notes/Evaluations

Other
Specify

Reason for disclosure:

Continued Care

Lawyer

Other

I understand that this will include information relating to:
Acquired Immunodeficiency Syndrome (AIDS) or Human Immunodeficiency Virus (HIV)
Behavioral Health Services/Psychiatric Care
Substance Abuse Records
This information is to be released via

mail or

facsimile to:
Phone/Fax #:

Name:
Address:
State:

City:

Zip Code:

The facility, its employees, officers, and physicians are hereby released from any legal
responsibility or liability for disclosure of the above information to the extent indicated and
authorized herein.
Signed:
Detainee Name & Date

Legal Representative:
Name, Relationship & Date (if applicable)

Witness:
Name & Date

Medical records will only be faxed to another healthcare facility or medical provider
Form DIHS – 003
12/07

 

 

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