An authorization for use and disclosure is a detailed document that gives covered entities permission to use protected health information for specified purposes, which are generally other than treatment, payment, or health care operations, or to discloseprotected health information to a third party specified by the individual.
Below is a copy of The Bellevue Hospital’s Authorization for Use and Disclosure form. When you complete and sign this form, health information about you will be released as you described in the form. Please read each section carefully and complete the required sections before signing. We encourage you to request a copy of your records and review them before authorizing the release of the records to someone other than you. Please clearly and legibly print all information when completing this form and sign at the bottom of the page.
Completion of this document authorizes the disclosure and/or use of health information about you. Failure to provide all information requested may invalidate this authorization.
Please return the completed form to the Health Information Management Department. If you have any questions, please call 419.483.4040, Ext. 4212.
Authorization for Use and Disclosure of Patient Information Form
Authorization for Use and Disclosure of Patient Information - SPANISH
