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Inmate Medical Records

This is an Authorization for release of patient medical health information. If authorizing disclosure to persons or organizations that are not health plans, covered health plans, covered health care providers or health care clearinghouses subject to federal health information privacy laws, they may further disclose the protected health information. However, genetic testing or HIV/AIDS information disclosed pursuant to this authorization may not be further disclosed except pursuant to authorization .
  • (enter name of facility)
  • Date Format: MM slash DD slash YYYY
  • (enter the purpose of disclosure)
  • (enter ID # DOB and Patient's Name)
  • I hereby release and hold harmless Correctional Healthcare Companies and its employees from any liability which may occur as a result of the disclosure of dissemination of the records or information contained therein resulting from the access permitted to the authorized attorney, health care facility, other as specified or self. I understand that I have the right to revoke this authorization at any time prior to disclosure by giving written (witnessed by someone who knows my identity) to the Facility Privacy Officer. I understand I have the right to inspect and receive a copy of the material disclosed. The identified health information may be provided verbally or over the phone to the person or entity identified above.
    This authorization will expire (check one).
  • Signature of Patient or Person Authorized to Consent - I certify under perjury in the second degree, that the above facts are true and correct to the best of my knowledge.
  • Date Format: MM slash DD slash YYYY