CAPZ16 Record Release Authorization Form v2

Record Release Authorization
NOTE: Patient should only provide name and date of birth and sign the form. Thank you!

Patient Name*

First NameMiddle NameLast Name

Date of Birth *

Date

Cape Regional Health System

The following information to be completed by Cape Regional
as needed for continuity of care purposes.

Facility: _______________________________________________________

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. This authorization will remain in effect for a period of one year from the date stated below unless revoked.

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 assure treatment. I understand that I may inspect or copy the information to be used or disclosed, as provided in CFR 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 and privacy regulations.

I certify that I am the person represented on this form or I have the legal authority to sign on their behalf. I also understand that the digital signature below is a valid legally binding signature.

Signature of patient or guardian*

Name of patient or guardian*

First NameLast Name