Policy Manual sample

MDT Home Health Care Agency, Inc. AUTHORIZATION FOR RELEASE OF INFORMATION Client’s Name: _________________________________________________________ Med. Rec. No: ___________ Start of Care Date: __________ Date of Birth:__________ 1. I hereby authorize ________________________________ to release to: _____________________________________________________________________ _____________________________________________________________________ 2. Information to be released: 9 Clinical Records 9 Daily Notes 9 Other (specify): 9 Evaluation 9 Clinical notes __________________________ 9 Test Results 9 Discharge Summary __________________________ 3. The above information is released for the following purpose and the purpose only. Any other use is forbidden. ____________________________________________________________________ ____________________________________________________________________ 4. I also understand that I may revoke this authorization at any time. 5. This authorization will expire thirty (30) days from the date of my signature or as otherwise specified by date, event or condition as follows: ____________________________________________________________________ ____________________________________________________________________ 6. With respect to any mental health information that may be contained in the client’s clinical records, I hereby waive my/his/her rights to the privileges of confidentiality. _____________________________ _______________________ Client Signature or Date legal representative Relationship to patient: _______________ Witness Signature: __________________ Home Health Agency - - Skilled Professional Services C-23