Authorization for Release of Protected Health Information to Patient
My signature below authorizes White House Clinics to disclose to me the following protected health information (PHI):
_______All Records Pertinent to Continuing Primary Care
_______Records Regarding Treatment of Specific Illness, Condition, or Injury
(please specify _________________________________________________________________)
_______Records Covering Period of Time from ______________ to ______________
_______Other (please specify____________________________________________________________)
My indication above acknowledges that I understand that this authorization may include the use or disclosure of
information concerning HIV testing, treatment of HIV/AIDS and related conditions, diagnosis and treatment of drug
and/or alcohol abuse, and psychiatric/psychological conditions to/from the organizations listed above.
The purpose of this disclosure is:
_______Future Medical Care
_______Legal Claim Processing
_______Insurance Claim Processing
_______Other (please specify ____________________________________________________________)
I wish to have the requested medical records given to me in the following form (please choose one):
_______Paper (within 10 business days)
_______CD (within 3 business days)
I understand that 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 Dr., Richmond, Kentucky 40475. I also
understand that the changes or cancellation will not affect action taken based on this authorization prior to the change
or cancellation.
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 Clinic may receive reimbursement from the above recipient for the expense of supplies
and labor necessary to disclose my personal health information.
This authorization expires on ________________________ (list specific day or event). I certify that I have received a
copy of this authorization (if I so choose).
___________________________________
___________________________________
Patient Name
Patient Date of Birth
___________________________________
___________________________________
Signature of Patient/Legal Guardian
Relationship to Patient (if other than self)
___________________________________
___________________________________
Signature of Witness
Date
McKee
Berea
Berea Primary Care
305 Estill Street
Berea, KY 40403
P: (859) 985-1415
F: (859) 985-6752
Richmond
Irvine
Mt. Vernon
30 Stacy Lane Rd 116 Progress Drive 11652 Highway 52 E
Irvine, KY 40336 Mt. Vernon, KY 40456 Paint Lick, KY 40461
P: (606) 256-2143 P: (859) 925-2444
F: (606) 256-9762 F: (859) 925-2334
Paint Lick
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
P: (606) 723-0665
F: (606) 723-0680
F: (859) 626-7703
HIPAA 002-01 Authorization for Release of PHI to Patient
Effective 7/2012