JOHNS HOPKINS INSTITUTIONS

AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION TO JOHNS HOPKINS

Complete all sections of this Authorization as appropriate to your request.

Patient Name:

(first)

(m. initial)

(last)

Birth Date:

Address:

(street address)

Phone #:

(city)

(state)

(zip code)

Medical Record #:

(if known)

For this authorization, "My Health Information" means:

(provide description of health information)

If I have initialed here (), "My Health Information" includes Substance Abuse Records/Information.

For the date(s) of service from:

(records should be provided for all service dates if left blank)

(insert date(s) of service requested)

I authorize

("Health Care Provider") to provide My

Health Information to for

(insert name of Johns Hopkins person or entity) (insert purpose for use or disclosure)

My Health Information should be faxed to OR sent to:

(insert street address)

(nsert city, state and zip code)

I understand that:

This Authorization is voluntary. My treatment will not be impacted, no matter if I sign this Authorization or not.
If I do not sign this Authorization, my Health Care Provider will not disclose My Health Information as requested.
This Authorization is valid for one year from the date signed, unless I revoke/withdraw this Authorization or unless an earlier date is specified here:

I may revoke/withdraw this Authorization, except to the extent that action has been taken prior to receipt of the revocation/withdrawal, by mailing or faxing my written request along with a copy of the original Authorization to the Health Care Provider identified above that provided health information to Johns Hopkins.
Once My Health Information is disclosed as requested, it may no longer be protected by federal and state privacy laws, and could be re-disclosed by the person(s) receiving it.
The medical information released may contain information related to HIV status, AIDS, sexually transmitted diseases, mental health, drug and alcohol abuse, etc.

Signature of Patient Only:

Date:

If you are NOT the patient but are signing on behalf of the patient, complete the following:

I, , am the (check which applies) (print your name)

Parent with Parental Rights (not sufficient for substance abuse records)
Registered Kinship Care Relative (not sufficient for substance abuse records)
Court Appointed Guardian
Legally Appointed Healthcare Agent (not sufficient for substance abuse records)
Medical Power of Attorney (not sufficient for substance abuse records)
Power of Attorney with Right to See Medical Records (not sufficient for substance abuse records)
Surrogate Decision Maker (not sufficient for substance abuse records or mental health records)
Court Appointed Personal Representative of Deceased

Representative’s Signature:

Date:

Address: Phone:

You MUST attach proof of your authority to act on behalf of the patient as checked above (other than parent)