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The form collects patient identifiers, release type (e.g., MyChart, CD, paper, EHI export, go anywhere, or other), source and recipient details, selected record categories, and handling of special protected records including AIDS/HIV, substance use, and mental health. 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It also requires the source facility and the recipient details, plus the specific records requested.","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"How do I specify which medical records I want released?",{"text":113,"@type":109},"Check the records you want listed on the form, such as discharge summaries, pathology reports, laboratory or imaging reports, immunization records, ER notes, surgery reports, outpatient notes, psychological test reports, research records, or other specified items.",{"name":115,"@type":106,"acceptedAnswer":116},"When does the authorization expire and can it be revoked?",{"text":117,"@type":109},"The authorization expires on the date listed; if no date is included, it expires in 90 days. It may be revoked at any time in writing to the Registration Office at the facility/location where it was submitted, except to the extent information was already used or disclosed based on the authorization.","https://schema.org",{"og:url":78,"og:type":120,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":122,"canonical":78},"index,follow",{"doc_id":124,"site_id":56},283968,1791285785,{"code":4,"msg":5,"data":127},{"doc_id":124,"user_id":128,"nickname":88,"user_avatar":129,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":15,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":73,"language":135,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":136,"faqs":137,"seo_title":138,"seo_description":61,"update_tm":139,"read_time":9},5909890329169,"https://ap-avatar.wpscdn.com/davatar_9964176cb1d06d4a9deccf72a44ae3dc","􀁺 University of Kentucky A. B. Chandler Hospital  \n􀁺 UK HealthCare Good Samaritan Hospital  \n􀁺 UK HealthCare Ambulatory Services  \n􀁺 UK Dental and Oral Health Clinics  \nAUTHORIZATION FOR RELEASE OF INFORMATION (for Use and Disclosure)  \nPlease fill out all sections or the form may be returned to you.  \nPatient Name:   Social Security Number:    \nAddress:   Date of Birth:    \nCity:   State:   Zip:   Phone Number:    \nType of Release  MyChart  CD  Paper  EHI Export (see Page 2 for more information)  Go Anywhere  Other    Pick-up--Phone number    \n\n| Send Information from: |  |\n| --- | --- |\n| | UK HealthCare facilities\u003Cbr>UK College of Dentistry\u003Cbr>University Health Service (Includes: UK Student Health / Employee Health / Urgent Care Clinic) |\n| Substance Use Disorder Clinic (provide clinic name) |  |\n|  Other   |  |\n\n Review records at UK (must make an appointment)  \n\n| Send to: email address (for Go Anywhere or MyChart USE  ONLY) or address (if name / address is different from |\n| --- |\n| above) |\n|  |\n|  |\n|  |\n|  |\n\nPlease check the records you would like: (Can be a very specific date or more general. Example: July 15, 2007 or June 2006-Feb 2007)  Records related to (specify):    \n Discharge Summary  Pathology Report(s) (examples: car accident or appendectomy)  \nTB Screening  Laboratory Report(s) X-Ray Report(s) X-Ray Image(s)  Photo/Video/Other  \n Immunization Record  ER Notes Surgery Reports Outpatient Notes  Psychological Test Report  \n Research Records  All records Other: (specify)    \nSharing of Special Protected Records: I authorize the sharing of information about:  \na. The diagnosis or treatment of AIDS, including the results of HIV tests (the virus that causes AIDS)  \nb. The diagnosis or treatment of drug and/or alcohol abuse  \nc. The treatment and/or consultation for mental health or psychiatric disorders  \nReason records are needed (check all that apply):  \n For my care Social Security/disability Legal Personal use Other (specify)  \nThis Authorization will expire on  (date).  \nIf no date is included the Authorization will expire in 90 days.  \n- I understand that I may revoke this Authorization at any time, unless the Authorization was obtained as a condition of obtaining insurance coverage; that my revocation must be submitted in writing to the Registration Office at the Facility/location where I originally submitted/filed this authorization; and that the revocation shall be effective except to the extent that the Facility has already used or disclosed information in reliance on the Authorization.  \n- I further understand that treatment payment, enrollment in any health plan, or eligibility for benefits is not conditioned on signing this Authorization, however, Facility may condition the provision of health care that is solely for the purpose of creating protected health information for disclosure to a third party on my signing this Authorization, and Facility may condition the provision of research-related treatment on my signing this Authorization.  \n- I understand that information used or disclosed pursuant to this Authorization may be subject to re-disclosure by the recipient and may no longer be protected by applicable privacy law. I further understand that the facility, its employees, officers and agents are released from legal responsibility or liability for the use and disclosure of the above information to the extent indicated and authorized.  \n-42 CFR part 2 prohibits unauthorized disclosure of these records.  \n- If the records we produce pursuant to this authorization include HIV or AIDs test results, that information has been disclosed to the recipient from records whose confidentiality is protected by state law. State law prohibits the recipient from making any further disclosure of such information without the specific written consent of the person to whom such information pertains, or as otherwise permitted by state law. A general authorization for the release of medical or other information is NOT ","cbCaitYi9V4V66v3","https://ap.wps.com/l/cbCaitYi9V4V66v3","pdf",152817,"English","# Authorization for Release of Information (for Use and Disclosure)\n## Patient and Request Details\n## Type of Release and Delivery Options\n## Records to Be Sent and Special Protected Records\n## Reasons, Expiration, Revocation, and Privacy Notices","[{\"question\":\"What information is required to complete the authorization form?\",\"answer\":\"The form requires patient name and contact identifiers, date of birth, address, phone number, and the selected type of release. It also requires the source facility and the recipient details, plus the specific records requested.\"},{\"question\":\"How do I specify which medical records I want released?\",\"answer\":\"Check the records you want listed on the form, such as discharge summaries, pathology reports, laboratory or imaging reports, immunization records, ER notes, surgery reports, outpatient notes, psychological test reports, research records, or other specified items.\"},{\"question\":\"When does the authorization expire and can it be revoked?\",\"answer\":\"The authorization expires on the date listed; if no date is included, it expires in 90 days. It may be revoked at any time in writing to the Registration Office at the facility/location where it was submitted, except to the extent information was already used or disclosed based on the authorization.\"}]","Authorization for Release of Information (for Use and Disclosure) - Medical Records | PDF",1789623600]