Records Release Form

Patient Name

Outgoing Records

I authorize the release of information held by the Bear River Health Department to:

Mail
Fax
Email

Incoming Records

If you need information sent to the BRHD please complete the following:

I authorize the release of information held by , and to be sent to the Bear River Health Department.

655 East 1300 North | Logan | Utah | 84341

Fax: 435-713-9531

Email:[email protected]

Information to Release

Immunization

Family Planning Record

Titer Results

USIIS Record Only

Last Pap Smear

EMS Labs

History & Physical

HIV/STD Results

Recent Lab Work

Immigration Information

Chest X-ray Results

Other:

I Understand:

1. This authorization will expire in 90 days after date on this form.

2. I may revoke this authorization at any time by notifying the providing organization in writing and that it will be effective on the date written notice is received.

3. Information used or disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and no longer be protected by Federal privacy regulations.

4. I may have a copy of the information described on this form and a signed copy of this form.

5. By Authorizing this release of information, I understand that my health care and payment for my health care will not be affected.

Application Signature

This information and any attached documents are confidential and may contain information that is protected from disclosure by federal and state law, including HIPPA (45 C.F.R., Part 164). This information is intended only for the use of the person named above. If you are not the intended recipient, be advised that any use, dissemination, forwarding, printing, or copying of this information is strictly prohibited. Please contact the sender by reply email and destroy all copies of the original message.

Please note this information was sent via a secure network once it leaves the health department network the information may no longer be secured.