Form ADPH-CHR-6A "Authorization for Disclosure/Request of Protected Health Information (Phi)" - Alabama

What Is Form ADPH-CHR-6A?

This is a legal form that was released by the Alabama Department of Public Health - a government authority operating within Alabama. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on January 1, 2003;
  • The latest edition provided by the Alabama Department of Public Health;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form ADPH-CHR-6A by clicking the link below or browse more documents and templates provided by the Alabama Department of Public Health.

ADVERTISEMENT
ADVERTISEMENT

Download Form ADPH-CHR-6A "Authorization for Disclosure/Request of Protected Health Information (Phi)" - Alabama

Download PDF

Fill PDF online

Rate (4.8 / 5) 82 votes
AUTHORIZATION FOR
PHALCON LABEL
Name ______________________________________________CHR # _____
DISCLOSURE/REQUEST OF PROTECTED
SSN
______________________________ Race _____ DOB __________
HEALTH INFORMATION (PHI)
Med# ______________________________ Sex _____ Date __________
Address ____________________________________ Phone ____________
I authorize the disclosure/request of
This information may be disclosed
the named individual’s health information
to/requested from and used by the
as described below. The following individual
following individual organization:
or organization is authorized to make
the disclosure/request:
_________________________________
Name of Recipient (Provider)
___________________________
_________________________________
Health Department
Address
___________________________
_________________________________
Address
City
State
Zip
___________________________
City
State
Zip
Additional Recipient (Provider): ______________________
________________________
The type and amount of information to be disclosed/requested is as follows:
Complete Medical Record
Medical Discharge Summary
History and Physical
Nursing Summary
Lab Reports (Specify) ____________________
Other: ____________________
_____________________
____________________
X-Ray
I understand that the information in my health record may include information relating to sexually transmitted
disease, acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV). It may also include
information about behavioral or mental health services, and treatment for alcohol and drug abuse.
I understand that I have a right to revoke this authorization at any time. I understand that if I revoke this
authorization, I must do so in writing. I understand that the revocation will not apply to information that has already
been released in response to this authorization. I understand that the revocation will not apply to my insurance
company when the law provides my insurer with the right to contest a claim under my policy. Unless otherwise
revoked, this authorization will expire one year from date signed.
I understand that authorizing the disclosure/request of this health information is voluntary. I can refuse to sign this
authorization. I need not sign this form in order to assure services/treatment. I understand that I may inspect or
copy the information to be used or disclosed, as provided in CFR Part 45 d 164.524. I understand that any disclosure
of information carries with it the potential for an unauthorized re-disclosure and the information may not be
protected by Federal confidentiality rules. If I have questions about disclosure of my health information or to present
my written revocation authorization I can contact:
____________________________
____________________________
______________________________________________
_________________
Signature of Patient/Legal Representative
Date
_______________________________________________________
_______________________
If signed by Legal Representative, Relationship to Patient
Signature of Witness
Permission To Disclose Information For Social Services
I hereby give permission to the Alabama Department of Public Health to disclose information about me/this minor
child to social service agencies, community agencies, and health care providers for the limited purpose of
consultation or referral. This permission may include the disclosure of information about my/this child’s medical
condition but does not include the release of the written medical record.
I have been given an opportunity to discuss how this form will be used. I know that I have the right to revoke this
permission at any time (except to the extent that action has already been taken). Unless otherwise revoked, this
authorization will expire one year from the date signed.
__________________________________________
______________________
Patient or Legal Representative
Date
C H R
6 A
ADPH-CHR-6A/Rev. 1-03-kw
AUTHORIZATION FOR
PHALCON LABEL
Name ______________________________________________CHR # _____
DISCLOSURE/REQUEST OF PROTECTED
SSN
______________________________ Race _____ DOB __________
HEALTH INFORMATION (PHI)
Med# ______________________________ Sex _____ Date __________
Address ____________________________________ Phone ____________
I authorize the disclosure/request of
This information may be disclosed
the named individual’s health information
to/requested from and used by the
as described below. The following individual
following individual organization:
or organization is authorized to make
the disclosure/request:
_________________________________
Name of Recipient (Provider)
___________________________
_________________________________
Health Department
Address
___________________________
_________________________________
Address
City
State
Zip
___________________________
City
State
Zip
Additional Recipient (Provider): ______________________
________________________
The type and amount of information to be disclosed/requested is as follows:
Complete Medical Record
Medical Discharge Summary
History and Physical
Nursing Summary
Lab Reports (Specify) ____________________
Other: ____________________
_____________________
____________________
X-Ray
I understand that the information in my health record may include information relating to sexually transmitted
disease, acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV). It may also include
information about behavioral or mental health services, and treatment for alcohol and drug abuse.
I understand that I have a right to revoke this authorization at any time. I understand that if I revoke this
authorization, I must do so in writing. I understand that the revocation will not apply to information that has already
been released in response to this authorization. I understand that the revocation will not apply to my insurance
company when the law provides my insurer with the right to contest a claim under my policy. Unless otherwise
revoked, this authorization will expire one year from date signed.
I understand that authorizing the disclosure/request of this health information is voluntary. I can refuse to sign this
authorization. I need not sign this form in order to assure services/treatment. I understand that I may inspect or
copy the information to be used or disclosed, as provided in CFR Part 45 d 164.524. I understand that any disclosure
of information carries with it the potential for an unauthorized re-disclosure and the information may not be
protected by Federal confidentiality rules. If I have questions about disclosure of my health information or to present
my written revocation authorization I can contact:
____________________________
____________________________
______________________________________________
_________________
Signature of Patient/Legal Representative
Date
_______________________________________________________
_______________________
If signed by Legal Representative, Relationship to Patient
Signature of Witness
Permission To Disclose Information For Social Services
I hereby give permission to the Alabama Department of Public Health to disclose information about me/this minor
child to social service agencies, community agencies, and health care providers for the limited purpose of
consultation or referral. This permission may include the disclosure of information about my/this child’s medical
condition but does not include the release of the written medical record.
I have been given an opportunity to discuss how this form will be used. I know that I have the right to revoke this
permission at any time (except to the extent that action has already been taken). Unless otherwise revoked, this
authorization will expire one year from the date signed.
__________________________________________
______________________
Patient or Legal Representative
Date
C H R
6 A
ADPH-CHR-6A/Rev. 1-03-kw