Purpose for Which Records will be Used
• Continuity of Care
• Legal
• Personal
• Other ____________________________
Legal Authority for Request (please initial)
___________ I am the resident noted above
___________ I am the resident 's attorney-in-fact, and I have attached to this authorization a valid power of attorney or Durable Power of Attorney for Health Care (DPAHC) that grants me the power to request the resident 's medical records. I understand that the resident 's DPAHC is effective only when the resident 's attending physician has determined that the resident has lost the capacity to make informed health care decisions.
___________ I am the resident 's legal guardian, and I have attached to this authorization a valid appointment of guardianship from a probate court.
___________ If the resident is deceased: I am the executor/administrator of the resident 's estate, and I have attached to this authorization a valid appointment as such from a probate court.
___________ The resident has executed a legally binding instrument granting me the authority to obtain his/her medical records, and I have attached a copy of that instrument to this authorization.
___________ The resident 's legally authorized representative has executed a legally binding instrument granting me the authority to obtain the resident 's medical records. I have attached a copy of the instrument granting me such authority, as well as evidence that the person who executed that instrument had the legal authority to do so, e.g. a power of attorney or probate court order.
Understanding and Agreements of Requestor
1. This authorization is voluntary and I understand that the facility cannot condition treatment based on the signing of this authorization, unless the authorization is (a) for research-related treatment, or (b) solely for the purpose of creating health information for the use or disclosure to a third party.
2. This authorization will expire 60 days from the date of my signature above.
3. I understand that I may revoke this authorization at any time by notifying the facility in writing.
4. I agree to waive all claims against the facility for the release of the requested information.
5. I understand that once the information described herein is disclosed, it may no longer be subject to the privacy protections afforded by the facility if the recipient of the information is not a health plan, health care provider, health care clearinghouse, or a business associate that has a contract with the facility.
6. I understand that I must provide the facility with at least twenty-four (24 hours) notice before coming to the facility to review records.
7. I understand that after I have reviewed the records, I must provide the facility with at least two (2) working days advance notice of any copies of the records that I would like t o pick up at the facility.
8. I understand that if I request that records be copied and sent to me that the facility will make a good faith effort to send those records to me in a reasonable amount of time.
9. I understand that if I wish to have copies of records made, then the facility will assess a fee for copying the records along with a postage fee (if applicable). The fee for copying records is $1.00 per page up to 25 pages; any additional pages are 25 cents each.
10. I understand that the facility will notify me of the total amount due for copying and shipping of the requested records; I agree that the facility will only send me the requested information once it has received payment in full for those costs.
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Signature of Person Making Request
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Printed Name of Person Making Request
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Date
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Facility Representative
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