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