Healthcare Clinic Release Of Information 51171 Walgreens HCC ROI Form

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RELEASE OF INFORMATION
FOR USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION

PLEASE MAIL OR FAX COMPLETED FORM TO:
Take Care Health Services
Attn: PSC – ROI Department
P.O. Box 691569, Orlando FL 32819

Phone: 855­925­4733
Fax: 888­297­8357

Medical records are kept in strict confidence and are not released without the written authorization of the patient except as permitted or required by law. I understand that
Take Care Health Services providers at Healthcare Clinic at select Walgreens have 30 days to respond to this request, Take Care Health may extend this 30 day response
period for another 30 days, and in certain circumstances Take Care Health may deny this request.

*Note: This form should be used if a patient would like a third party to receive their health information on an ongoing basis or will require
multiple disclosures over a designated period of time to a third party.
AUTHORIZATION FOR USE AND DISCLOSURE OF INFORMATION

Patient Name:

Date of Birth:

Street Address:
City:

State:

Telephone:

Fax:

Zip:
Email:

Release to:
*If this form is being completed by patient or guardian a copy of your PHOTO ID is required*
Name/Business:
Address:
City, State, Zip:
Phone Number:

Fax Number:

Email:
SPECIFIC DESCRIPTION OF INFORMATION TO BE USED AND DISCLOSED
Please indicate the time period you are requesting records for. Dates of Service From: __________ To: __________
Entire Medical Record
Diagnosis/Treatment notes
Lab/X­rays
Physical forms

Billing Information
Immunization records
Referral
Other: _____________________
PURPOSE OF THE USE AND DISCLOSURE

Diagnosis & Treatment
Insurance/Billing
Other: _________________________________

Legal
Personal

METHOD FOR RECEIVING YOUR DISCLOSURE (Check only one box below)

Paper
Email

In an effort to protect your health information, our standard practice is to encrypt our email. If your preference is to receive
unencrypted email, please sign below. By signing below, you acknowledge that you understand an unencrypted email exposes your person and
health information to additional security risks.

Signature: _____________________________________

PATIENT AGREEMENT:
I authorize the use and disclosure of my individually identifiable health information as described above, including verbal and written exchanges about the information unless I
indicated otherwise. I understand that this authorization is voluntary. I understand that if the person or organization I authorize to receive the information is not my health plan
or my health care provider, the released information may no longer be protected by federal privacy regulations and could be re­disclosed. I understand that my health care and
payment for my health care will not be affected if I do not sign this form. I release the Take Care Health Services providers at select Walgreens, Take Care Health Systems, LLC,
Walgreen Co., and each of their respective subsidiaries, affiliated companies, directors, officers, employers, employees, attorneys, and agents from all legal responsibility and/or
liability that may arise from the release of the records I have specified.
I understand that I may revoke this authorization in writing at any time, except to the extent action has already been taken with reliance on it. I authorize the Take Care Health
Services providers at Healthcare Clinic at select Walgreens to use or disclose of protected health information as described above.

_________________________________________

_____________________________________________________

Signature of Patient or Representative

Date

©2014 Walgreen Co. All rights reserved.

_______________________________________________
Printed Name of Personal Representative

______________________________________________________________
Relationship to the patient /representative’s authority to act on behalf of the patient

EXPIRATION DATE ­ This Authorization will expire one (1) year from the date of your signature.

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Walgreens-HCC ROI form revised(81551890_2).DOC

©2014 Walgreen Co. All rights reserved.



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