If you are a medical provider, then you might want to draft a form that your patients can use. Set it up as a template, and insert blank lines for information that will change depending on the patient.
You could write: “I authorize Piedmont Medical Practice to use and disclose my protected health information described below to Dr. Caryn Smith, 2222 High Street, City, Nevada, 12345. ”
Sample language could read: “This authorization for release of health information covers the period of healthcare from August 1, 2013 to April 2, 2016. ” Alternately, you could state that your release should cover “all past, present, and future periods. ”
If you want to release everything, then include this language: “I authorize the release of my complete health history (including all information related to HIV or AIDS, mental health care, communicable diseases, or treatment of alcohol and drug abuse). ” If you only want to release specific records, then you can state exactly what you want released. Alternately, you could state that you release your complete health history except for certain information. State what information should be held back.
You can write, “This authorization shall be in effect until August 31, 2016. ” Or you could write, “This authorization shall be in effect until the date of my surgery. ”
“I understand I may revoke this authorization in writing at any time. My revocation is not effective to the extent someone has already acted on my authorization or if my authorization was obtained so that an insurer can contest a claim. ” “This medical information may be used by the person I authorize to receive it for medical treatment, consultation, or other purposes as I direct. I understand that my payment, enrollment, eligibility for benefits, or treatment will not be conditioned on whether I sign this authorization. ” “I understand that the information used or disclosed by this authorization may no longer be protected by state or federal law. ”
Hand deliver the release to your doctor or mail it certified mail, return receipt requested.
You don’t have to type a business letter, though you can if you want. Instead, you can just type up a form so long as it includes all of the necessary information. If you are creating a template for parents to use, then include this information as a header: “This form grants temporary authority to an adult to arrange for and provide medical care in the event of an emergency for an unaccompanied minor when it is not possible to contact the parents or legal guardians. Please give your signed form to the trip leader. ”
Sample language could read: “We, Alice and Alexander Smith, hereby grant Melissa Jones of 5555 Southern Drive, Cityscape, NV 12345 the authority to obtain medical treatment for our child, Evan Kevin Smith. ”
home address date of birth gender
You should also include medical insurance information, such as the name of the plan and the policy number.
Also note all treatment your child is receiving. For example, if your child has asthma, then include that information. If your child takes medicine, list the medicines and the dosages that they receive. [11] X Research source
administer general first aid summon emergency medical personnel if the injury is life threatening or requires immediate emergency treatment X-rays anesthetic blood transfusions medication any other treatment deemed advisable by appropriate medical professionals
For example, you could write: “This authorization is given in advance of any medical treatment. However, it is given to provide the Designated Adult with the expectation that he/she will use their best judgment upon the advice of medical personnel. This authorization is effective through September 1, 2017. ”
You can find a notary at most courthouses, town or city offices, and large banks. Make sure to bring sufficient personal identification, such as a valid passport or state-issued ID. You will probably have to pay a small fee to use a notary.
