Can anyone tell us how this form should be filled out for I-day.
Thanks,
Diannne
DEPARTMENT OF THE AIR FORCE
10TH MEDICAL GROUP
USAF ACADEMY, COLORADO
(Date)
MEMORANDUM FOR SGST
FROM:
(Individual Authorizing Release)
SUBJECT: Authorization to Release Medical Records
1. The Privacy Act of 1974 and AFI 41-210, Patient Administration Function reads as follows:
Direct Disclosure: Information may be released directly to the patient or authorized representatives of the person concerned upon receipt of a written request from the patient (or legal representative). An abstract of the case (or copies of pertinent pages of the record) may be furnished to the person, or authorized representative when a person departs on a temporary absence from home and requires medical care while away. Written Consent: Do not release information from health records to any person or agency without written consent of the patient concerned or his/her legal representative. For deceased persons, the next of kin (NOK) or a court appointed executor or administrator signs as individual authorizing release. The guardian must provide a court order appointing guardianship. Prohibition on Redisclosure: This information has been disclosed to you from records whose confidentiality is protected by federal law. Federal Regulation [42 CFR Part (21 U.S.C. 4582)] prohibit you from making any further disclosure of this information without the specific consent of the person whom it pertains. A general authorization for the release of medical or other information is NOT sufficient for this purpose.
2. Principle purpose: To enable authorization form to be filed in patient's health record(s) for a period not to
exceed 1 (ONE) year. TERMINATION: Unless sooner revoked or terminated by me, this letter shall become
NULL and VOID from and after: (DATE) . Upon expiration, a re-
submittal will be required for release of the medical records.
3. Nature of disclosure: Disclosure of SSAN is voluntary; however, failure to disclose SSAN will delay or
prevent filing of this authorization form and hamper access of records.
BRETT A. NEWTON, SSGT, USAF USAFA Release of Information Office
(Date)
1st Ind, /
(Full Name & Rank/Status of Person Authorizing Release) (SSN of Sponsor)
MEMORANDUM FOR 10 MEDICAL OPERATIONS SQ/SGOXO
I hereby authorize pick up any and all medical records, including but not limited to inpatient, outpatient and x-rays to:
(Full Name of Person Authorized to Pick up Records) (Relationship to Releaser)
(Signature & Date of Releaser) (Signature of Outpatient Records Clerk)
(Notarized: Optional only if this letter is not completed in the hospital)
Thanks,
Diannne
DEPARTMENT OF THE AIR FORCE
10TH MEDICAL GROUP
USAF ACADEMY, COLORADO
(Date)
MEMORANDUM FOR SGST
FROM:
(Individual Authorizing Release)
SUBJECT: Authorization to Release Medical Records
1. The Privacy Act of 1974 and AFI 41-210, Patient Administration Function reads as follows:
Direct Disclosure: Information may be released directly to the patient or authorized representatives of the person concerned upon receipt of a written request from the patient (or legal representative). An abstract of the case (or copies of pertinent pages of the record) may be furnished to the person, or authorized representative when a person departs on a temporary absence from home and requires medical care while away. Written Consent: Do not release information from health records to any person or agency without written consent of the patient concerned or his/her legal representative. For deceased persons, the next of kin (NOK) or a court appointed executor or administrator signs as individual authorizing release. The guardian must provide a court order appointing guardianship. Prohibition on Redisclosure: This information has been disclosed to you from records whose confidentiality is protected by federal law. Federal Regulation [42 CFR Part (21 U.S.C. 4582)] prohibit you from making any further disclosure of this information without the specific consent of the person whom it pertains. A general authorization for the release of medical or other information is NOT sufficient for this purpose.
2. Principle purpose: To enable authorization form to be filed in patient's health record(s) for a period not to
exceed 1 (ONE) year. TERMINATION: Unless sooner revoked or terminated by me, this letter shall become
NULL and VOID from and after: (DATE) . Upon expiration, a re-
submittal will be required for release of the medical records.
3. Nature of disclosure: Disclosure of SSAN is voluntary; however, failure to disclose SSAN will delay or
prevent filing of this authorization form and hamper access of records.
BRETT A. NEWTON, SSGT, USAF USAFA Release of Information Office
(Date)
1st Ind, /
(Full Name & Rank/Status of Person Authorizing Release) (SSN of Sponsor)
MEMORANDUM FOR 10 MEDICAL OPERATIONS SQ/SGOXO
I hereby authorize pick up any and all medical records, including but not limited to inpatient, outpatient and x-rays to:
(Full Name of Person Authorized to Pick up Records) (Relationship to Releaser)
(Signature & Date of Releaser) (Signature of Outpatient Records Clerk)
(Notarized: Optional only if this letter is not completed in the hospital)