Authorization for Release of Protected Health Information Patient Name : 
 	___ Date of Birth: _____/_____/_____ 
 	Phone: 
 	I request that my protected health information (PHI) be disclosed to/obtained from ( circle one): □ Disclosure to patient 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 covering the period of healthcare from: _____________ to ______________ 
 	____ ONLY White House Clinics records 
 	( Please use specific dates) 
 	Records Regarding Treatment of Specific Illness, Condition, or Injury ( please specify) ___ 
 	All Pharmacy Records 
 	____ Other: ( please specify) 
 	___ 
 	 State and federal law protect the following information. If this information applies to you, please indicate if you would like this 
 	 information released/obtained (include dates where appropriate): 
 	Alcohol, Drug, or Substance Abuse Records 
 	□ Yes 
 	□ No 
 	Dates: 
 	
 	___ 
 	HIV Testing and Results 
 	□ Yes 
 	□ No 
 	Dates: 
 	
 	___ 
 	Psychotherapy Records 
 	□ Yes 
 	□ No 
 	Dates: 
 	___ ___
 	Reviewed and Approved by: ___________________________________________ 
 	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.): Paper (within 10 days) Fax Secure E-mail CD (within 3 business days) 
 	P atient Portal 
 	Other (please specify): 
 	 ______________ 
 	 ___ 
 	By signing this authorization form, I confirm I have been made aware of the rights and conditions listed on the back of this form:  ________________________________________ 
 	 ______________________________________________ 
 	Patient or Authorized Representative 
 	Signature Date 
 	________________________________________ 
 	______________________________________________ 
 	Print Name 
 	Relationship to Patient ( if other than self) 
 	________________________________________ 
 	______________________________________________ 
 	Witness Signature ( Verified by) 
 	Witness Signature Date 
 	Richmond Location: 
 	401 Highland Park Drive, Richmond, Kentucky 40475 
 	Phone: (859) 626-7700 Fax: (859) 626-7703 
 	Berea Location: 
 	104 Legacy Drive, Berea, Kentucky 40403 
 	Phone: (859) 986-2323 Fax: (859) 986-7728 
 	Berea Primary Care Location: 305 Estill Street, Berea, Kentucky 40403 
 	Phone: (859) 985-1415 Fax: (859) 986-6752 
 	McKee Location: 
 	1010 Main Street South, McKee, Kentucky 40447 
 	Phone: (606) 287-7014 Fax: (606) 287-3323 
 	Irvine Location: 
 	30 Stacy Lane Road, Irvine, Kentucky 40336 
 	Phone: (606) 723-0665 Fax: (606) 723-0680 
 	Mt. Vernon Location: 116 Progress Drive, Mt. Vernon, Kentucky 40456 
 	Phone: (606) 256-2143 Fax: (606) 256-9762 
 	Paint Lick Location: 
 	480 Main Street, Paint Lick, Kentucky 40461 
 	Phone: (859) 925-2444 Fax: (859) 925-2334 
 	Lancaster Location: 
 	89 Farra Drive, Lancaster, Kentucky 40444 
 	Phone: (859) 792-2153 Fax: (859) 458-4038 
 	*This is a 2-sided form
 	02/2018 

 	
 	
 	Rights and Conditions 
 	• I am authorizing White House Clinic to disclose/obtain certain protected health information (PHI) about me to the party or parties listed above. 
 	• 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 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 additional disclosure 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 disclosed protected health information that is received via secure email may not be protected after opening. 
 	• 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 is a 2-sided form 

 	
 	02/2018