PATIENT AUTHORIZATION FOR THE DISCLOSURE
OF PROTECTED HEALTH INFORMATION
TO ANOTHER FACILITY
______________________________________________________ ____________________________
Name of Patient (please print) Date of Birth
______________________________________________________ ____________________________
Street Address City State Zip Phone Number
______________________________________________________
Maiden name or other name used for on records
I hereby authorize: To release to: (please print)
Mount Laurel Family Physicians ________________________________________________________
204 Ark Road, Suite 103 ________________________________________________________
Mount Laurel, NJ 08054 ________________________________________________________
I understand that this may include information relating to
- Acquired Immunodeficiency Syndrome (AIDS) or Human Immunodeficiency Syndrome (HIV) infection
- Psychiatric care
- Treatment for alcohol and/or drug abuse
This information is to be disclosed for the purpose(s) of ____________________________________________________
Specify the date, extent or condition upon which this authorization expires ______________________________________
I understand that I have the right to revoke this authorization at any time. I understand that in order to revoke this
authorization, I must do so in writing and present my written revocation to Mt Laurel Family Physicians at the above
address. I understand such revocation will not apply to information already released in response to this authorization. I
understand that the revocation will not apply to my insurance company when the law provides my insurer with the right to
contest a claim under any policy. Unless otherwise revoked, this authorization will expire in 6 months from the date below.
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.
I understand that fees may be charged for preparing and sending copies of records according to the following policy:
$20.00 flat fee to cover postage and administrative costs as well as the last five (5) years of records. Additional years of
records will be provided at your request at the cost of $1.00 per page, with a maximum charge of $100.00. Only records
generated by Mt Laurel Family Physicians and any consulting physician(s) will be included. Medical records from previous
physicians will not be released. They must be obtained from those specific practitioners.
_________________________________________________________ ___________________________________
Signature of Patient (18 years or older) or Legal Representative Date
_________________________________________________________ ___________________________________
Printed Name of Patient’s Representative Relationship to Patient