Medical Records Release

The releasing provider listed above is hereby authorized to release information from the medical records of the above named patient. This authorization permits release of information to include information such as psychological or psychiatric impairments, drugs use and/or alcoholism, information indicating HIV related test, HIV infection, HIV related illness, AIDS or any information which could indicate potential exposure to HIV and any information related to or regarding genetic testing.

I understand that Community Memorial Hospital will not condition treatment on my providing authorization for disclosure. I further understand that I do not have to allow the release of this information in part or entirety. I acknowledge that I have the right to revoke this authorization at any time by sending written notification to Community Memorial Hospital, Privacy Officer, 150 Broad Street, Hamilton, NY 13346. I understand that a revocation will not apply to information that has already been released.

I understand that the information to be released from the medical record is confidential and will not be released except to the person/institution named below. I acknowledge that any disclosure to a third party can lead to unauthorized re-disclosure by that person or others, which may not be subject to federal or state confidentiality laws.

Please note: All scanned records to any external email address (e.g. gmail, yahoo, etc.) must be encrypted for security purposes. If the email address you provide is an external address, the information you receive will be encrypted. To open the email, you must follow the directions in the registration process. Electronic medical records requested (CD or Email) are only available (if the medical record is dated from 07/01/2010 to present. Records requested that are older than 10 years are subject to retention and destruction policy and procedure.)