Form 8710.48E 4/02 REV. 4/03
PrnShp - POD
AUTHORIZATION FOR RELEASE OF INFORMATION
(For Record Release from Arnot Ogden Medical Center)
I hereby authorize the use or disclosure of my individually identifiable health information as described below. I
understand that this authorization is voluntary. I understand that if the organization authorized to receive the
information is not a health plan or health care provider, the released information may no longer be protected by federal
privacy regulations.
Patient Name:
Patient Address:
Date of Birth:
SS Number:
Patient Phone:
Persons/organizations providing the information:
Arnot Ogden Medical Center
600 Roe Avenue
Elmira NY 14905
Phone: 607-737-4302
Fax: 607-737-4403
Persons/organizations receiving the information:
Specific description of information
Abstract (all dictated notes, face Discharge Summary
Radiology Records
sheets, lab, X-rays, EKGs)
Entire Emergency Record Labs
History & Physical
Operative Note Dr. Orders
Progress Notes
Pathology Records
Nurses Notes
Consultation
Anesthesia Record
Other:___________________________________ Type of access requested: Inspection_____ Copies_____
Patient will be charged $.75 per page for copies and any additional costs incurred, including postage, films, photos, etc.
Patient will be charged for the cost of furnishing an original mammogram.
Date(s) of Requested Information:
1. What is the purpose of the use or disclosure?________________________________________________________
2. I understand that this authorization will expire on ___/___/___ or upon compliance with the request for
information, whichever occurs first. Initials:_______________
3. I understand that I may revoke this authorization at any time by notifying the providing organization in writing,
But if I do, it won't have any effect on any actions they took before they received the revocation. Initials:______
MUST BE COMPLETED ONLY IF A HEALTH PLAN OR HEALTH CARE PROVIDER HAS REQUESTED
THE AUTHORIZATION.
I understand that my health care and the payments for my health care will not be affected if I do not sign this form.
Initials:_______________
___________________________________________________ ________________________________________
Signature Date
Relationship, if not patient:__________________________________________________________________________
___________________________________________________ ________________________________________
Notary Public/AOMC Witness Date
*YOU MAY REFUSE TO SIGN THIS AUTHORIZATION*
Special Authorization required for drug, alcohol, HIV and psychiatric information
To be Completed by AOMC Staff Date Completed:_________________________ Initials:_______________
MR #: ___________________Number of Pages Sent:________________
Mailed Faxed Hand Delivered
