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The form documents disclosure purpose, what information to release (e.g., ultrasound copies, depo/PACA proofs, full chart, FMLA paperwork, billing or appointment notes), and the authorization end date. 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ID as    \nI hereby authorizeDCWC to release my protected health information to:  \n Myself  Another facility/physician for treatment:    \nFacility/Physician Name  \n Fax/Email to:    \n Mail to:   Name Address  \nCity State Zip Code  \n Hold for pick up by (valid identification will be required before records are released):  \nName Relationship  \nPurpose of Disclosure:  \n Myself  School/Work Appointment proof  Legal  Proof of Depo Administration  Treatment at another facility Other (specify):    \nInformation to be released (check all that apply)  \n Copy of ultrasound(s)  Proof of Depo Shot  \n Full copy of chart (may be  For Completion of  \nsubject to a charge) FMLA paperwork  \n Other (please describe and be as specific as possible):  \n Proof of PACA  Billing info  Appointment note with restrictions  \nThis authorization shall be in force and effect until: (check one of the following)  \n One Year from the date the Authorization is signed.  \n Date    \nI understand that, as set forth in the facility's Privacy Notice, I have the right to revoke this authorization, in writing, at any time, but that the revocation will apply only to uses and disclosures of my PHI after the revocation. I can request revocation by sending written notification to:  \nDelaware County Women’s Center  \nAttn: Privacy Officer  \nCCMC Annex-Alexander Silberman Center  \n1 Medical Center Blvd., 4th Floor  \nUpland, Pa 19013  \nI understand that authorizing the disclosure of this health information is voluntary and that the facility will not condition my treatment on whether I provide authorization for the requested use of disclosure. 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 federal or state law. I understand that I may inspect or copy the information tobe disclosed for a reasonable charge.  \nI have carefully read and understand the above, have had any questions explained to my satisfaction and to herein expressly and voluntarily authorize disclosure of the above information about, or medical records of my condition to those persons or agencies listed above.  \nPatient Signature   Date    \n--For Staff Use Only--  \nRequest completed in the presence of   or Request received via fax/email  \n______________  \nRequest fulfilled by   Date/Time    \nEntered in Centricity   Date/Time  \\","cbCairbAE9jo9MQA","https://ap.wps.com/l/cbCairbAE9jo9MQA","pdf",156802,"English","# Patient Authorization Details\n## Recipients and Delivery Information\n## Purpose of Disclosure and Released Information\n## Authorization Duration and Revocation Rights\n## Patient Signature\n# Staff Use Only\n## Receipt, Fulfillment, and System Entry","[{\"question\":\"Who can Delaware County Women’s Center release the patient’s protected health information to?\",\"answer\":\"The form authorizes disclosure to the patient, another facility/physician for treatment, or other specified persons or entities listed on the form.\"},{\"question\":\"What types of information can be released using this form?\",\"answer\":\"The patient can check items such as ultrasound copies, Proof of Depo Shot, full chart (subject to a charge), FMLA paperwork, Proof of PACA, billing info, and appointment notes with restrictions.\"},{\"question\":\"How long is the authorization valid and how can it be revoked?\",\"answer\":\"Authorization remains in force until one year from the signature date or until the specific date checked on the form. The patient may revoke in writing at any time, and revocation applies to uses/disclosures of PHI after the revocation.\"}]","Delaware County Women’s Center - Medical Record Release Form - Template | PDF",1789849779]