Urologic Associates of Iowa City P.C.

Authorization for Release of Health Information

Please print:

Patient Name _________________________________ Birth Date ___________ Social Security Number _____________________

Last First MI

I understand by signing this form, I am allowing _________________________________________________________________

Name of Facility/Provider

______________________________________________________________________________________________________

Facility Mailing Address/Street/PO Box City, State, Zip Code Fax Number

To Release medical information concerning the above named patient to:

______________________________________________________________________________________________________

Name of Person and/or Institution

______________________________________________________________________________________________________

Complete Mailing Address/Street/PO Box City, State, Zip Code Fax Number

Medical Information Requested:

Check the information to be disclosed (included dates where indicated) _______ Minimum necessary or specify:

_____Medication list _____Allergy list _____Problem list

_____Most recent history and physical or specific date ____________________________________________________________

_____Most recent discharge summary or specific date _____________________________________________________________

_____Consultation reports, specify doctor or clinic _______________________________________________________________

_____Laboratory results, specify type or date ___________________________________________________________________

_____X-ray and imaging reports, specify type or date _____________________________________________________________

_____Test results (i.e. CMG, EKG, etc), specify type and date _______________________________________________________

_____Billing information, specify _____________________________________________________________________________

_____Other, specify ______________________________________________________________________________________

As per my request, the release of information is for ______medical care _______legal ______insurance ______other

If other, specify __________________________________________________________________________________________

I understand I may revoke this authorization at any time by sending written notice to the above named provider of information. I understand that any release, which was made prior to my cancellation in compliance with this authorization, shall not constitute a breach of my rights to confidentiality. Disclosure of this information carries with it the potential for unauthorized redisclosure and once information is disclosed, it may no longer be protected by federal privacy regulations. I understand that I may review the disclosed information or ask questions by contacting the office that disclosed the information.

I understand that the information to be released may include information in the following categories unless I specifically deny the release (initial any category not to be released)

Substance abuse ______ Mental health_______ HIV related information_______

Restrictions:_____________________________________________________________________________________________

This agreement will expire one year from the date of signature, unless previously revoked or otherwise indicated (specify number of days or months)_____________________

___________________________________________________________________________________________________________

Signature of patient or legal guardian Date

___________________________________________________________________________________________________________

Complete Mailing Address/Street/PO Box City, State, Zip Code

____________________________________________________________________________________________________________

Relationship if not the patient Witness Signature

FOR OFFICE USE ONLY:

v Records will be mailed to address above Records prepared by________________

v Records will be picked up on Date prepared_____________________ rev4-06

v Records may be faxed to number listed above