Last First MI
ID#
(Place patient label here)
Student Health Services
The Ohio State University
1875 Millikin Road, Columbus, OH 43210
Phone: 614-292-0118 Fax: 614-292-7042
Email: [email protected]
AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION
Please print. Incomplete forms will not be processed. See reverse side for instructions and fees.
1.
PATIENT WHOSE INFORMATION IS TO BE RELEASED
Name _____________________________________________________________________________________________
Last First Middle Initial Maiden/Other
Date of Birth ______ /_____ /______ Preferred Phone Number ______________________________________
Month Day Year
2.
PERSON/ORGANIZATION WHO IS RECEIVING OR RELEASING INFORMATION
I authorize OSU Student Health Services to:
Release health information to
OR
Obtain health information from
*select only one*
Name/Facility
Address
City/State/Zip
Phone Number
Fax Number OR Email
3.
TYPE OF INFORMATION TO BE RELEASED
Office Visit Notes (includes Primary Care, Preventive Medicine, Allergy and Nutrition)
Gynecology Notes Optometry Notes Dental Notes Dental Images Physical Therapy & Sports Medicine
Radiology Reports Laborat
ory Immunizations Other (please specify): _______________________________
4.
DATES OF INFORMATION TO BE RELEASED
Information released will fall within this date range: _________________ t
o _________________
Month/Day/Year Month/Day/Year Month/Day/Year
Future dates of
service will not be
honored.
5.
METHOD OF RELEASE
Information will be released by: Mail Fax Pick-Up Verbal/Phone Email *select only one*
6.
PURPOSE OF RELEASE
Personal Use Continued health care Academics Employment Legal Other (specify): ________________
7.
PATIENT RIGHTS AND SIGNATURE
I understand that the information in my health record may include information relating to sexually transmitted infections (STI), acquired
immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV). It may also include information about behavioral or mental health
services and treatment for alcohol or drug abuse. I understand that this authorization is valid for 60 days, unless revoked by my written notice,
provided said notice is received prior to release of the above designated information. I understand that authorizing the disclosure of this health
information is voluntary. I can refuse to sign this authorization. I need not sign this form in order to receive treatment. I understand there may be a
charge for record copies. I understand that any disclosure of information carries with it the potential for an unauthorized re-disclos
ure and the
information may not be protected by federal confidentiality rules. If I selected email as the method of release, I understand that email is not a secure
form of communication as email communication can be intercepted in transmission or misdirected. I understand that the choice to have my protected
health information emailed is at my own risk. If I have questions about the disclosure of my health information, I may contact the Health Information
Manager.
______________________________________________ ___________ ____________________
Signature of Patient or Legal Representative** Date Legal Relationship
(**paperwork must be submitted with this request) (if not the patient)
FOR OFFICE USE ONLY
Request received in HIS ________________ on by ____________
Date HIS Staff Initials
Patient unable to sign: Minor Telephone Consent Other: ________
Request ___________________ on ______________ by________________ Info provided at time of service Payment Received: __________
(mailed, faxed, etc.) Date Staff Initials/Service Area Date
Revised 07/2020 AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION Page 1
INSTRUCTIONS
All sections must be completed in their entirety.
1. P
atient Information: Complete the entire section to clearly and legibly identify patient - entire patient name
(and any previous names), date of birth and phone number.
2. Re
ceiving Party: Identify the full name/organization, address, phone and fax number of the recipient of your
health information. Please allow 7-10 days for processing.
• Select only one: Do you want to SHS to release information? OR Do you want SHS to obtain information?
• If the requested release will be made by mail, provide the complete address.
• If the requested release will be made by fax, provide the fax number.
• If the requested release will be made by email, please provide the email address.
3. In
formation to be Released: Be very specific about the information you need released. For example, types of
visits or the name of the physician or provider who treated you.
4. Dates to be Released: This can be a very specific date or more general. For example, July 15, 2012 or June
2012 - Feb 2013. You may not request future dates of service. For example, if you complete this form on June 1,
2014, you may not authorize the release of progress notes from an appointment that is scheduled on June 30,
2014.
5. Me
thod of Release: How will your information be delivered? Select only one method and be sure to provide
address, fax number or email address in section number 2 (see above).
6. Purpose of Release: Please identify why you need a copy of your record. This helps us to track and assign a
priority status to your request. It also informs us who may be responsible for the cost of records (where
appropriate).
7. Righ
ts/Signature: Your handwritten signature and date of form completion are required.
N
o Charge
FEE SCHEDULE (In accordance with Ohio Revised Code 3701.742)
Provider/Healthcare Facility:
(Records must be mailed/faxed to the provider listed)
Personal Copy:
(No charge for copies of immunization records)
Third Party:
(Not related to continuing care)
Attorney and Insurance Company:
(
Including subpoenas/excluding claims processing)
Radiology and Dental Films:
$8.00
$8.00
$20.24 records search fee
$1.34/per page (pages 1 – 10)
$0.69/per page (pages 11 – 50)
$0.27/per page (pages 51+)
$2.27/per film
(No charge when requested by a provider)
Revised 7/2020 AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION Page 2
