2. Authorize Release From (if different from PHCM)
Leave blank if authorizing PHCM to release your records to a third party listed in Section 3.
3. Release Records To
4. Records Requested
Select all that apply:
Complete Medical Record Office Visit Notes Lab / Diagnostic Results Imaging Reports Medication / Prescription History Immunization Records Referral Letters Operative / Procedure Reports Discharge Summary Billing / Insurance Records Other (specify below)
5. Purpose of Disclosure
Continuing Medical Care Personal Use / Copy Insurance / Benefits Legal / Attorney Disability Determination Workers' Compensation School / Employment Research (IRB-approved) Other (specify below)
6. Preferred Delivery Format
Secure Electronic Copy (email / portal) Printed Copy (standard fee may apply) Fax to Provider / Facility Mail (standard fee may apply)
Important Notices: You have the right to revoke this authorization at any time by submitting a written request to PHCM, except to the extent that action has already been taken in reliance on this authorization. Revocation does not apply to uses or disclosures already made. You may refuse to sign this authorization. Signing is not a condition of receiving treatment, payment, enrollment, or eligibility for benefits, except where the disclosure is for research-related treatment or is made to a third-party payor for payment purposes. Information disclosed pursuant to this authorization may be re-disclosed by the recipient and may no longer be protected by HIPAA. A fee may apply for printed or mailed copies per Mississippi state guidelines.
7. Expiration
8. Legal Representative (if signing on behalf of patient)
Power of Attorney Guardianship Order Court Authorization Birth Certificate (minor) Other
9. Signature
I certify that the information above is accurate and that I am authorized to request this disclosure. A copy of this authorization is as valid as the original.