INFORMATION TO BE RELEASED OR OBTAINED (The next two sections must be completed to properly identify the records to be released)
METHOD OF DELIVERY
- I understand the release of my records will be for the purpose stated on this form and only those items checked off or listed will be released. This authorization automatically expires
six (6) months from the date of the patient's or personal representative's signature.
- I understand I may revoke this authorization at any time, provided that I do so in writing. I understand the revocation will not apply to information that has already been released in response to this authorization. I understand the revocation will not apply to my insurance company when the law provides my insurer with the right to contest a claim under my policy.
- I understand that once the information is disclosed pursuant to this authorization, it may be re-disclosed by the recipient and the information may not be protected by federal privacy regulations. I understand the recipient may be prohibited from disclosing substance abuse information under federal substance abuse confidentiality requirements.
- I understand this authorization must be signed by the patient. I understand if the patient is under eighteen (18) years of age, legally incompetent, or is unable to sign, the parent or legal representative must provide authorization. I understand I may refuse to sign this authorization and that my refusal to sign will not affect my ability to obtain treatment or payment or my eligibility for benefits.
- In the case of a minor child; I certify no Court Order is currently in force that would prohibit my access to these records or prohibit my power to consent upon another person.
- I understand I am entitled to a copy of this authorization form after signing.
- I understand West Virginia State Laws (§16-29-2) indicates that a reasonable fee may be charged for copies of healthcare records and I agree to pay these fees.
- I understand copies of my healthcare records that are provided for my continued care will be provided to the healthcare provider at no charge.
- I certify and acknowledge that I have read this form or had it read to me. All my questions have been answered and I request that the records be released as described above.