PO Box *****, Las Vegas, NV *****-**** • Fax: 1-678-***-****

Authorization to Disclose Protected Health Information (PHI) PD6259 (04/21) Page 1 of 2

This request to release medical records will be returned if not completed in its entirety Patient Name: Date of Birth: MRN:

Address:

City: State: Zip Code:

Check the clinic name/s of where you’re requesting release of medical records:

Southwest Medical (Part Of OptumCare) OptumCare Orthopaedics and Spine

OptumCare Primary Care OptumCare Lung and Allergy Care

OptumCare Cancer Care OptumCare Radiation Oncology (Dr. Becker)

OptumCare Breast Care Urology Specialists of Nevada

OptumCare Community Center

I authorize the use or disclosure of the above named individual’s Protected Health Information as described below:

The type and amount of information to be used or disclosed is as follows Include dates where appropriate – From (date): Through (date):

Entire record, Or:

Medication List Immunization Records Provider Notes

Laboratory Results X-Ray/Dexa Reports Cardiology Reports

Billing

Other:

Please initial for release of the following information even if you checked “Entire Record” above HIV Information Psychiatric / Mental Health Information Addictive Behavior Genetic Test Results

Child & Domestic Abuse History Substance Abuse

Communicable and Sexually Transmitted Disease

Note: Information pertaining to substance abuse diagnosis or treatment requires completion of the Consent for Release of Confidential Health Information under 42 C.F.R. Part 2 – Confidentiality of Alcohol and Drug Abuse Patient Records.

I understand that I have a right to revoke this authorization at any time. I understand that if I revoke this authorization I must do so in writing and present my written revocation to the health information management department. I understand that the revocation will not apply to information that has already been released in response to this authorization. Unless otherwise revoked, this authorization will expire on the following date, event, or condition: If left blank, this authorization will expire in six months PO Box 15645, Las Vegas, NV 89114-5645 • Fax: 1-678-***-**** Authorization to Disclose Protected Health Information (PHI) PD6259 (04/21) Page 2 of 2

This information is to be disclosed to Requestor the following individual or organization Name Phone number Fax number

Address City, State, Zip

I understand that authorizing the disclosure of this health information is voluntary. I can refuse to sign this authorization. I need not sign this form in order to assure treatment. I understand that I may inspect or obtain a copy of the information to be used or disclosed, as provided in CFR 164.524. I understand that any disclosure of information carries with it the potential for an unauthorized redisclosure and the information may not be protected by federal confidentiality rules. If I have questions about disclosure of my health information, I can contact the Health Information Management Department and obtain a copy of the Privacy Notice.

I wish to receive this information on

Paper CD (as a PDF file)

Email - By providing your email address, you agree to receive emails from Southwest Medical Associates regarding your medical history (lab results, blood panel results, clinic visit notes and summaries, physician notes, and more).

Email address:

Verify email address:

Signature of Patient: Date of Signature

Signature of Parent, Guardian or Date of Signature Representative (if necessary):

(If Personal Representative, attach supporting documentation) NOTE: There is a charge not to exceed $25 for copies of records unless information is being disclosed to a medical facility. Please allow 7-10 business days from date of receipt by HIM Department for processing. Phone: 702-***-**** Mon-Fri, 8am-5pm The company does not discriminate on the basis of race, color, national origin, sex, age, or disability in health programs and activities. We provide free services to help you communicate with us. Such as, letters in other languages or large print. Or, you can ask for an interpreter. To ask for help, please call 702-***-****. ATENCIÓN: Si habla español (Spanish), hay servicios de asistencia de idiomas, sin cargo, a su disposición. Llame al 702-***-****. 請注意 如果您說中文 (Chinese) 我們免費為您提供語言協助服務 請致電 702-***-**** Routed to:

By:

Date:

Completed: Y N

Scanned by: (initial)

Photo ID checked by:

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