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MountainStar Medical Group
Authorization for Release of Information Form

Section A: This section must be completed for all Authorizations

Patient Name
Patient's Phone
Date of Birth
Patient Last 4 digits SSN
(optional)
Request Dates of Service
Facility Name(s) and Addresses
Recipient’s Name
Recipient Address
City, State
Zip
Recipient’s Phone Recipient’s Fax Number
Email (for releases to email)
Purpose of disclosure
; or
Request Delivery (If left blank, a paper copy will be provided)

There is some level of risk that a third party could see your information without your consent when receiving unencrypted electronic media or email. We are not responsible for unauthorized access to the PHI contained in this format or any risks (e.g., virus) potentially introduced to your computer/device when receiving PHI in electronic format or email. Note: In the event the facility is unable to accommodate an electronic delivery as requested, an alternative delivery method will be provided (e.g., paper copy).

This authorization will expire after 180 days or on the following (please choose only one):
Description of information to be used or disclosed










Other Records:







For USCDI Release Requests

To include all elements as defined in the United States Core Data for Interoperability. Requires Direct Address or National Provider Identifier:

All types of information found in the records selected above will be provided (if applicable), including information that may be viewed as sensitive, such as alcohol, drug abuse, genetic information, psychiatric, HIV testing, HIV results or AIDS information. Specify any information you want to exclude:

I understand that:

  1. I may refuse to sign this authorization and that it is strictly voluntary.
  2. My treatment, payment, enrollment or eligibility for benefits may not be conditioned on signing this authorization.
  3. I may revoke this authorization at any time in writing, but if I do, it will not have any effect on any actions taken prior to receiving the revocation. Further details may be found in the Notice of Privacy Practices.
  4. If the recipient is not a health plan or health care provider, the released information may no longer be protected by federal privacy regulations and may be redisclosed.
  5. I understand that I may see and obtain a copy the information described on this form, for a reasonable copy fee, if I ask for it.
  6. I get a copy of this form after I sign it.

Section B: Is the request of PHI for the purpose of marketing and/or does it involve the sale of PHI?

If yes, the health plan or health care provider must complete Section B, otherwise skip to Section C.

Will the Provider receive financial remuneration in exchange for using or disclosing this information?
If yes, describe
May the recipient of the PHI further exchange the information for financial remuneration?

Section C: Signatures

I have read the above and authorize the disclosure of the protected health information as stated.

Signature of patient or personal representative Date
Printed name of patient or personal representative Relationship to patient

6/2021 Revised PHY 08/2021