Authorization for Release of Protected Health Information
Patient Name ____________________________________________________________
Date of Birth: ____/____/______
I request that my protected health information (PHI) be disclosed to/obtained from (circle one):
Recipient Name: ________________________________________________________________________________________________________________
Address: _____________________________________________________________ City:____________________ State: _____ Zip: ________________
Fax (healthcare provider only): ____________________________________________________________________________________________________
I authorize the following PHI to be released from my medical record(s):
______ All Records Pertinent to Continuing Primary Care
______ Records Covering Period of Time from __________________ to __________________
______ Records Regarding Treatment of Specific Illness, Condition, or Injury (please specify) _________________________________________________
______ All Pharmacy Records
______ Other (please specify _____________________________________________________________________________________________________)
I understand that the information in my health record may include information relating to sexually transmitted disease (STD), aquired immunodificiency
syndrome (AIDS), or human immunodeficiency virus (HIV). It may also include information about behavioral or mental health services, and treatment of
alcohol or drug abuse.
State and federal law protect the following information. If this information applies to you, please indicate if you would like this information
released or obtained (include dates where appropriate):
Alcohol, Drug, or Substance Abuse Records
Records regaurding HIV Testing and Results
Mental Health (LCSW)
Yes
Yes
Yes
Yes
No
No
No
No
Dates:________________________________________________________
Dates:________________________________________________________
Dates:________________________________________________________
Dates:________________________________________________________
Psychotherapy Records
Purpose for requesting information: Legal
Insurance
Personal
Continuation of Care
Other (please specify other on line below):
______________________________________________________________________________________________________________________________
Disclosure Format (Paper is default if not marked.):
US Mail
Fax
Secure E-Mail
CD
Patient Portal
Other (please specify): ____________________________________________________________
By signing this authorization form, I understand that:
• I am authorizing White House Clinics to disclose/obtain certain protected health information (PHI) about me to the party or parties listed above.
• I certify that I have no knowledge of any action which would alter my rights to the aforementioned records.
• I have the right to change or cancel this authorization at any time by notifying the Privacy Officer, in writing at Health Help, Inc., Attention: Privacy
Officer, 401 Highland Park Drive, Richmond, Kentucky 40475. Revocation will not apply to information that has already been disclosed in response to
this authorization.
• I understand that unless otherwise revoked, this authorization will expire 1 year from the date signed.
• I understand that I do not have to sign this authorization and that White House Clinics cannot condition treatment or payment on whether I sign this
authorization.
• I understand that information used or disclosed based on this authorization may be subject to redisclosure by the recipient named above and may not be
protected by federal laws and regulations regarding the privacy of my protected health information. I understand that I have the right to inspect and copy
the information to be disclosed.
• I understand that White House Clinics may receive reimbursement from the above recipient for the expense of supplies and labor neccessary to disclose
my personal health information.
________________________________________
Patient or Authorized Representative Signature
________________________________________
Signature Date
________________________________________
Print Name
________________________________________
Relationship to Patient (if other than self)
________________________________________
Witness Signature
________________________________________
Witness Signature Date
McKee
Berea
Berea Primary Care
305 Estill Street
Berea, KY 40403
P: (859) 985-1415
F:(859) 985-6752
Richmond
Irvine
Mt. Vernon
Paint Lick
Lancaster
89 Farra Drive
Lancaster, KY 40444
P:(859) 792.2153
F:(859) 458.4038
1010 Main St South
McKee, KY 40447
P:(606) 287-7104
F:(606) 287-4409
104 Legacy Dr.
Berea, KY 40403
P: (859) 986-2323
F: (859) 986-7728
401 Highland Park Dr.
Richmond, KY 40475
P: (859) 626-7700
F: (859) 626-7703
30 Stacy Lane Rd.
Irvine, KY 40336
P:(606) 723-0665
F:(859) 723-0680
116 Progress Drive
Mt. Vernon, KY 40456
P:(606) 256-2143
F:(606) 256-9762
480 Main Street
Paint Lick, KY 40461
P:(859) 925-2444
F:(859) 925-2334
Effective 7/2017

 
Authorization for Release of Protected Health Information Through Email
Patient Name :____________________________________________________________
Date of Birth: ____/____/______
I request that my protected health information (PHI) be disclosed via secure email to:
Recipient Name: ______________________________________________________________________________________________________
Address: _____________________________________________________________ City:____________________ State: _____ Zip: _________________
E-mail Address: _____________________________________________________
Phone: _________________________________________________
Fax (healthcare provider only): _____________________________________________________________________________________________________
I authorize the following PHI to be released from my medical record(s):
______ All Records Pertinent to Continuing Primary Care
______ Records Covering Period of Time from __________________ to __________________
______ Records Regarding Treatment of Specific Illness, Condition, or Injury (please specify) _________________________________________________
______ All Pharmacy Records
______ Other (please specify _____________________________________________________________________________________________________)
I understand that the information in my health record may include information relating to sexually transmitted disease (STD), aquired immunodificiency
syndrome (AIDS), or human immunodeficiency virus (HIV). It may also include information about behavioral or mental health services, and treatment of
alcohol or drug abuse.
By signing this authorization form, I understand that:
• I am authorizing White House Clinics to disclose/obtain certain protected health information (PHI) about me to the party or parties listed above.
• I certify that I have no knowledge of any action which would alter my rights to the aformentioned records.
• I have the right to change or cancel this authorization at any time by notifying the Privacy Officer, in writting at Health Help, Inc., Attention: Privacy
Officer, 401 Highland Park Drive, Richmond, Kentucky 40475. Revocation will not apply to information that has already been disclosed in response to
this authorization.
• I understand that unless otherwise revoked, this authorization will expire 1 year from the date signed.
• I understand that I do not have to sign this authorization and that White House Clinic cannot condition treatment or payment on whether I sign this
authorization.
• I understand that information used or disclosed based on this authorization may be subject to redisclosure by the recipient named above and may not be
protected by federal laws and regulations regarding the privacy of my protected health information. I understand that I have the right to inspect and copy
the information to be disclosed.
• I understand that White House Clinics may receive reimbursement from the above recipient for the expense of supplies and labor neccessary to disclose
my personal health information.
________________________________________
Patient or Authorized Representative Signature
________________________________________
Signature Date
________________________________________
Print Name
________________________________________
Relationship to Patient (if other than self)
________________________________________
Witness Signature
________________________________________
Witness Signature Date
McKee
Berea
Berea Primary Care
305 Estill Street
Berea, KY 40403
P: (859) 985-1415
F:(859) 985-6752
Richmond
Irvine
Mt. Vernon
Paint Lick
Lancaster
89 Farra Drive
Lancaster, KY 40444
P:(859) 792.2153
F:(859) 458.4038
1010 Main St South
McKee, KY 40447
P:(606) 287-7104
F:(606) 287-4409
104 Legacy Dr.
Berea, KY 40403
P: (859) 986-2323
F: (859) 986-7728
401 Highland Park Dr.
Richmond, KY 40475
P: (859) 626-7700
F: (859) 626-7703
30 Stacy Lane Rd.
Irvine, KY 40336
P:(606) 723-0665
F:(859) 723-0680
116 Progress Drive
Mt. Vernon, KY 40456
P:(606) 256-2143
F:(606) 256-9762
480 Main Street
Paint Lick, KY 40461
P:(859) 925-2444
F:(859) 925-2334
Effective 7/2017