The purpose of this request is to share protected patient information with another Healthcare entity for the purpose of continued treatment. An abstract of the last year will be provided unless otherwise specified. Medical records will be faxed or emailed only to verified valid recipients. You may be contacted by the telephone number provided for further clarification and validation.
The undersigned authorizes Simpson General Hospital and Clinics to release my health information as noted below:
AUTHORIZATION FOR USE AND DISCLOSURE OF INFORMATION FROM SIMPSON GENERAL HOSPITAL AND CLINICS TO ANOTHER HEALTHCARE ENTITY OR PROVIDER
Pursuant to HIPAA 45 CFR, 164.524, we reserve the right to charge a reasonable cost-based fee for producing and mailing the copies. If you want the entire medical record, the rate will increase proportionally based on the cost. At no time will the cost-based fees exceed Mississippi State Law Statute 11-1-51.
I understand that: I may refuse to sign this authorization and that it is strictly voluntary. My treatment, payment, enrollment, or eligibility for benefits may not be conditioned on signing this authorization. I may revoke this authorization at any time in writing, but if I do, it will not have any effect on any actions taken prior to receiving the revocation.
If I do not specify expiration, this authorization will expire in 90 days. If the requester or receiver is not a healthcare provider, the released information may no longer be protected by Federal Privacy Regulations and may be disclosed. I understand that I may see and obtain a copy of the information described on this form, for a reasonable copy fee, if I ask for it. I can request a copy of this form after I sign and date it.
Please confirm that you have filled out this form in its entirety - if the form is incomplete or invalid, we may be unable to fulfill this request.
