Discharge Summary                              Progress Notes
History/Physical Exam                            Physician Orders
Emergency Room Report                    Operative/Procedure Reports
Consultation(s)                                        Medications (MAR)
Clinical Reports (lab, x-ray, EKG, etc)    

Social History
Psychological/Psychiatric/CDU               Nursing Notes
Entire Chart Radiology Images/Films

Other: _______________________________________________________________________________________

NOTICE TO PARTY RECEIVING SUBSTANCE USE DISORDER INFORMATION: 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 information in this record that identifies a patient as having or having had a substance use disorder either directly, by reference to publicly available information, or through verification of such identification by another person unless further disclosure is expressly permitted by the written consent of the individual whose information is being disclosed or as otherwise permitted by 42 CFR part 2. A general authorization for the release of medical or other information is NOT sufficient for this purpose. The federal rules restrict any use of the information to investigate or prosecute with regard to a crime any patient with a substance use disorder. PROHIBITION ON REDISCLOSURE: This information is confidential and protected by Federal Law. Any further redisclosure is strictly prohibited unless patient provides specific written consent for the subsequent disclosure of this information.

3. This authorization does NOT allow access to records for treatment that occurs after the date that this form is signed. This authorization only allows access to records for treatment that occurred prior to or on the date this form is signed for the period specified by the Expiration date.

4. The purpose of this disclosure is: _____________________________________________________________

5. I understand that if anyone who receives my health information is not a health care provider or a health plan, my health information may not be protected by federal privacy laws if my health information is redisclosed by the recipient of this information.

6. Parkview Medical Center may not use as a condition of treatment, payment, enrollment or eligibility for benefits on whether the individual signs this authorization except as allowed by law.

7. Expiration Date: ___________________________. This authorization shall remain in effect for a period of one year unless otherwise specified. This authorization may be revoked by me, in writing, at any time.

8. I understand that Parkview Medical Center will respond to this request within 3-5 business days unless I am otherwise notified.

9. I understand that Parkview Medical Center may charge me for copies of my health information according to the Colorado Department of Public Health and Environment Rules and Regulations.

10. Signature: ___________________________________________Date:_______________________Time:______
                                           Patient or Responsible Party

11. How would you like to receive your Health Information? CD Mailed CD Pick Up View Only

Paper Mailed Paper Pick Up

_ ____________________________________________________________________________________________
Revised 10/2015 Y1000 Authorization for Use and Disclosure of Health Information patient ID

Fax completed form to Health Information Services: 719-584-7379