Authorization for Release of Information to the Media Template by gigi12


									         Authorization for Release of Information to the Media Template

                                                                                             Public Information Office
                                                      (LOGO)                                                      Fax:

                    Authorization for Release of Information to the Media

Patient Information:

        Last Name                                           First                             Middle Initial

Medical Record Number                              Date of Birth                      Telephone Number

I hereby authorize the (Organizational Name) and its representatives to release protected health information
about me to the following media organization(s):

(Name of Person Allowed)

    Address                                        City                      State                      Zip

I authorize the (Organizational Name) to release Protected Health Information about me to any news,
entertainment or other media organization, including but not limited to television, radio, print, Internet or other

         Initial Required: ________

This authorization applies to the following information:
(Important: check the appropriate box or boxes and initial or sign and date as required.)

         MEDICAL – Initial Required: ________

         MENTAL HEALTH*
                                                            Signature and Date Required

                                                                                                               Page 1 of 3
         DRUG/ALCOHOL*
                                                                      Signature and Date Required

         Genetic Testing Information
                                                                      Signature and Date Required

         Reference to or RESULTS of an HIV BLOOD TEST*
                                                                                           Signature and Date Required

         OTHER (Please be specific)
        *The information maintained by (Organizational Name) may include information related to treatment or diagnosis of drug/alcohol,
        mental health and/or results of an HIV blood test. If you do not check these boxes, that information will not be released. Also, if
        you check any of these boxes, additional legal requirements regarding that information may apply before release can be made.

I understand that the purpose of this disclosure is for the media to further disclose this information to the public
by various means, including but not limited to: publications, internet sites, and television and radio broadcasts. I
do not hold (Organizational Name) responsible for the accuracy of news reports based on the information
released under this authorization.

Limitation on Release: I do not want the following specified information to be released to the media.
If no limitation, please write “No limitation.”

USES: The person who receives the health information can use it only for the following reason(s):



Duration: This authorization is valid immediately and will be valid until:

Date:                                               If I do not write a date this authorization will expire six months from
the date it was signed.

Cancellation: I understand that I have a right to cancel this authorization at any time. A cancellation must be
submitted in writing to the Public Information Officer at address at the top of this form. The cancellation will
become effective after it is received by the Public Information Officer. I understand that a cancellation will not
apply to actions already taken by (Organizational Name) under this authorization.

Conditions: I understand that treatment, payment, enrollment, or eligibility for benefits will not be based on my
giving or refusing to give this authorization. I also understand that I may refuse to sign this authorization.

Additional Copy: I understand that I have a right to receive a copy of this authorization if I ask for it.

Copy requested and received:           Yes                No ____________ (Initial)

                                                                                                                                  Page 2 of 3
                                           Patient/representative                           Date

Medical Record Number

If signed by other than patient, state relationship and authority to sign: _

Signature of Witness:                                                 Date:

              A copy of this completed form should be filed with the patient’s medical record.

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