Medical Records

I, (*) hereby authorize Memorial Health System, which is comprised of Marietta Memorial Hospital, Selby General Hospital and Sistersville General Hospital, to release copies of medical and other information concerning my hospitalization or treatment including, but not limited to, information concerning drug abuse or drug-related conditions, alcoholism, psychological and psychiatric conditions, and including the release of information containing HIV testing, AIDS diagnosis, AIDS related conditions or sexual preference, or permit review of same, provided, however that such release is limited specifically to material of the following nature and extent. I understand that any disclosure of information carries with it the potential for an unauthorized re-disclosure resulting in my health information no longer being protected by Federal confidentiality rules.

Your Email: (*)

Treatment Date:

Patient Type: Inpatient Emergency Outpatient

Patient Name: (*)

Date of Birth:

Social Security Number:

Records disclosed by: Marietta Memorial Hospital Selby General Hospital Sistersville General Hospital

Release Type: Complete Chart Operative/Pathology Report Case Summary Face Sheet Physician Orders/Progress Notes Nursing Notes History/Physical Emergency Room Report Test Results Other:

Specific Exclusions:

What person or facility is the above information to be released to? (*)

Address of person or facility:

Email address of person or facility: (*)

Fax Number:

Delivery Method: Pick-Up US Mail Fax Unencrypted Email (please be advised that Email is not fully secure when transmitted over the Internet)

Purpose of Disclosure: Insurance Continuity of Care Personal Legal Other:

REDISCLOSURE IS PROHIBITED WITHOUT SPECIFIC WRITTEN CONSENT OF THE PERSON TO WHOM IT PERTAINS

I understand this authorization may be revoked at any time except to the extent action has been taken prior to revocation. This consent will expire in one year after the date below or sooner at my election in which case this authorization will expire on I release the hospital of any liability which may arise as a result of any subsequent disclosure of my health information by the recipient.

Date:

SIGNATURE OF PATIENT: (*)

WITNESS: (*)

OTHER PERSON LEGALLY AUTHORIZED TO GIVE CONSENT:

RELATIONSHIP:

Memorial Health System may not condition the provision of treatment on the signing of this authorization. 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 written consent of the person to whom it pertains. A general authorization for the release of medical and other information is not sufficient for this purpose. According to State law there may be a per page fee charged for records. The fee will be dependent on the number of copies requested and other reasons as specified in ORC 3701.741 at codes.ohio.gov or WV Code Section 16-29-2 at code.wvlegislature.gov.