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      --Papillion Family Medicine--Medical Records Transfer Authorization--

Records of ­­­Name: ­­­______________________ Date of Birth: ­­­­­­­­­­­­­­­­­­_______________

FROM: ☐ Papillion Family Medicine   ☐ Other Clinic/Doctor

SEND TO: ☐ Papillion Family Medicine ☐ Self (☐ Mail ☐ Pickup) or ☐ Other Clinic/Doctor

Provider: ☐ Dr. Mantler ☐ Dr. Naegele ☐ Brooke Dorwart, PA-C ☐ Maddie Olson, PA-C

Name and address for: Self, Other Doctor, Other Clinic: (Street, City, State, Zip, Fax #)

__________________________________________________________________

I hereby authorize the transfer of records concerning the above patient for the Following

Dates: From _____________________ to _______________________ or ☐ All dates.

Information to be disclosed (check all that apply):

☐ Chemical dependency reports   ☐ Discharge summary ☐ School reports   ☐ Lab

☐ Mental Health Evaluation   ☐ History and physical   ☐ Rehab notes   ☐ X-ray

☐ Clinic notes/progress notes         ☐ Other ____________________________

By signing this document, I understand that all of the following may be released:

Acquired Immunodeficiency Syndrome (AIDS) or infection with Human Immunodeficiency Virus (HIV), Mental Health Information and Treatment for alcohol and/or drug abuse.

Papillion Family Medicine, its physicians, mid-level providers, and employees are hereby released from any legal responsibility or liability for disclosure of the above information to the extent indicated and authorized herein. The recipient of this patient information is prohibited from disclosing the information to any other party and is required to destroy the information after the stated need has been fulfilled. Following NE statue 71-8404, I understand that I may be charged $0.50 per page and $20 copying fee.

This information may be protected by Federal Confidentiality Rules (42 CFR Part 2). The Federal rules prohibit any third party from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42 CFR Part 2. A general authorization for the release of medical or other information is not sufficient for this purpose. The Federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse patient.

 

Signature of Patient ____________________________ Date ­­­­___________________

 

Signature of Parent/Guardian _____________________ Date ­___________________

(If Patient is Minor/Power of Attorney.  If Power of Attorney, must provide court invocation.)

 

Papillion Family Medicine, 555 Fortune Dr., Papillion NE 68046, P: 402.502.3600

Fax: 402.502.3606

Thought of the Day:
"Kindness is never wasted."--Aesop
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