This required section identifies the patient, the name of the current health care provider and the new provider where records are to be transferred. Press [CTRL+F1] for more information.
This required section addresses specially protected medical information. These records are given special protection to encourage treatment. Press [CTRL+F1] for more information.
This required section prohibits the redisclosure of the medical records. Press [CTRL+F1] for more information.
This required section specifies when the authorization will expire. Press [CTRL+F1] for more information.
This required section provides a signature line and shows the date of signing. Press [CTRL+F1] for more information.
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Authorization for Transfer of Medical Information
AFTOMI
The Authorization for Transfer of Medical Records allows a person to authorize the transfer of his/her medical records from a health care provider (e.g., a physician, nursing home or hospital) to a new health care provider.
!!! ! ! !
Enter the name of the patient requesting the transfer of medical records. Use the P.I. Manager to select and paste a record. Press [Ctrl+F1] for more information.
The program completes the Patient's name by transferring the information from a previous section. If someone else is signing for the Patient, that person's name should be entered. Use the P.I. Manager to select and paste a record. This signature line relates only to the specially protected information.
Enter an X if the person signing the authorization is the Patient. This signature line relates only to the specially protected information. A second signature is required at the end of the document also.
Enter an X if the person signing the authorization is the guardian of the Patient. This signature line relates only to the specially protected information. A second signature is required at the end of the document also.
Enter an X if the person signing the authorization is the Attorney-in-Fact for the Patient. In other words, the Patient has signed a Power of Attorney giving someone else the authority to act for the Patient.
Enter the relationship in which the person is acting on behalf of the patient. For example, a spouse of an incompetent person, a conservator appointed by a court, or other representational capacity.
TMI01
! Authorization For Release (1 of 5)
AUTHORIZATION TO
TRANSFER MEDICAL RECORDS
PATIENT'S NAME: !
DATE OF BIRTH: !
! PREVIOUS NAME: !
SOCIAL SECURITY NUMBER: !
1. AUTHORIZATION FOR RELEASE. I hereby authorize ! of !, !,
!, ! !,
to release, disclose and deliver the following information to:
AUTHORIZED RECIPIENT:
!, ! !
Enter the name of the patient requesting the transfer of medical records. Use the P.I. Manager to select and paste a record. Press [Ctrl+F1] for more information.
Using the format MM/DD/YYYY, enter the Patient's date of birth or edit the information as desired.
Enter an X to include a prior name the Patient may have used. The health care provider may have filed records under the prior name.
Enter the prior name used by the Patient.
Enter the Patient's social security number or edit the information as desired. Many offices file medical records by the Patient's social security number.
Enter the name of the health care provider ("Provider"). Use the P.I. Manager to select and paste a record. This may be the name of a physician, clinic, or other health care organization which maintains the Patient's medical records.
Enter the Provider's street address or edit the information as desired.
Enter the Provider's extended street address or edit the information as desired.
Enter the Provider's city or edit the information as desired.
Enter the Provider's state/province or edit the information as desired.
Enter the Provider's zip/postal code or edit the information as desired.
Enter the name of the new health care provider ("New Provider"). Use the P.I. Manager to select and paste a record. This may be the name of a physician, clinic, or other health care organization.
Enter the New Provider's street address or edit the information as desired.
Enter the New Provider's extended street address or edit the information as desired.
Enter the New Provider's city or edit the information as desired.
Enter the New Provider's state/province or edit the information as desired.
Enter the New Provider's zip/postal code or edit the information as desired.
Enter an X to include the New Provider's country, if outside the United States.
Enter the New Provider's country or edit the information as desired.
TMI02
! Specially Protected Information (2 of 5)
2. SPECIFIC AUTHORIZATION.
! I specifically authorize the release of all medical information relating to me including but not limited to the following categories protected by state or federal law: (1) Substance abuse (drug or alcohol) treatment; (2) Mental Health treatment; and (3) HIV/AIDS-related information, if such information is contained in my records.
! I specifically authorize the release of all medical information relating to the above-named patient except information relating to:
! - Substance abuse (drug or alcohol) treatment
! - Mental health treatment
! - HIV/AIDS-related information
! [Other]- !
! I specifically authorize the release of only the following information: !
I do not give permission for any other use or redisclosure of this information.
Dated __________________________________________
________________________________________________
! Patient
! Legal Guardian
! Attorney in Fact for !
! [Other] Relationship: !
Enter an X if this release relates to all categories of medical information, including substance abuse, mental health treatment and HIV/AIDS related information. Certain types of records are given special treatment to encourage diagnosis and treatment of these conditions. Press [Ctrl+F1] for more information.
Enter an X if this release will restrict the types of information that may be released.
Enter an X if this release DOES NOT permit the transfer of medical records relating to substance abuse (drug or alcohol) treatment. Press [Ctrl+F1] for more information.
Enter an X if this release DOES NOT permit the transfer of medical records relating to mental health treatment. Press [Ctrl+F1] for more information.
Enter an X if this release DOES NOT permit the transfer of medical records relating to HIV/AIDS related information. Press [Ctrl+F1] for more information.
Enter an X to specify another illness or form of treatment for which this release DOES NOT permit the transfer of medical records. Press [Ctrl+F1] for more information.
Enter the specific illness or form of treatment.
Enter an X to specifically list the types of medical information that may be released. For example, information relating to a specific condition that is being referred to a specialist.
Enter a brief explanation of the type of information that may be released. Be as specific as possible, perhaps including dates of treatment, so that no more information than necessary is released.
The program completes the Patient's name by transferring the information from a previous section. If someone else is signing for the Patient, that person's name should be entered. Use the P.I. Manager to select and paste a record. This signature line relates only to the specially protected information.
Enter an X if the person signing the authorization is the Patient. This signature line relates only to the specially protected information. A second signature is required at the end of the document also.
Enter an X if the person signing the authorization is the guardian of the Patient. This signature line relates only to the specially protected information. A second signature is required at the end of the document also.
Enter an X if the person signing the authorization is the Attorney-in-Fact for the Patient. In other words, the Patient has signed a Power of Attorney giving someone else the authority to act for the Patient.
Enter an X to indicate some other capacity in which the person is signing on behalf of the Patient. This signature line relates only to the specially protected information. A second signature is required at the end of the document also.
Enter the relationship in which the person is acting on behalf of the patient. For example, a spouse of an incompetent person, a conservator appointed by a court, or other representational capacity.
TMI03
! Redisclosure (3 of 5)
[Access Document Information for an explanation of the prohibited Redisclosure of released records.]
3. REDISCLOSURE. This release does not authorize redisclosure of medical information beyond the limits of this consent. The Recipient of this information is prohibited from using the information for other than the stated purpose, and from disclosing it to any other party.
This information has been disclosed to you from records protected by Federal confidentiality rules (42 CFR Part 2). The Federal rules prohibit you 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.
I specifically understand and agree that the REDISCLOSURE requirements set out above will apply to these records.
TMI04
! Validity Section (4 of 5)
4. VALIDITY. I understand that this release will automatically expire
! one year
! ! months
from the date of my signature, and that I may revoke this release by sending a written notice to the person or entity authorized to make the disclosure described above. I agree that any release which has been made prior to revocation and which was made in reliance upon this authorization shall not constitute a breach of my rights to confidentiality.
Enter an X if the authorization will be valid for a period of one (1) year. The consent should be valid no longer than necessary. The maximum recommended period is one year. Press [Ctrl+F1] for more information.
Enter an X to specify a shorter period of authorization.
Enter the number of months that the authorization will be valid.
TMI05
! Signature Section (5 of 5)
I authorize the release of information as indicated above.
Dated __________________________________________
________________________________________________
! for !
PATIENT'S ADDRESS: !
! Country: !
The program completes the Patient's name or the person signing on behalf of the Patient by transferring the information from a previous section. You may modify the information only by returning to that section. This assures that both signature lines in the document are consistent.
Enter the Patient's current street address or edit the information as desired.
Enter the Patient's extended street address or edit the information as desired.
Enter the Patient's city or edit the information as desired.
Enter the Patient's state/province or edit the information as desired.
Enter the Patient's zip/postal code or edit the information as desired.
Enter an X to include the Patient's country, if outside the United States.
Enter the Patient's country or edit the information as desired.
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