Dubuque Neurology and Sleep Medicine, P.C.

I authorize Dubuque Neurology and Sleep Medicine, P.C. to allow release of or request from another party my protected health information (medical records) as outlined in this authorization. Please complete all areas of information to insure a complete authorized request.

Today's Date *

Full Name-Last, First, Middle Initial *

Date of Birth *

Social Security Number *

Purpose of Disclosure *

Action Requested for this release: *

Release To

Request From

Verbally Exchange with

To Review only

All the above

Release information TO/FROM: *

Name, Address, Phone Number, Fax Number if available

Information to be released: *

Entire Medical Record

Laboratory Testing

Radiology Reports

Neurological Testing

Cognitive Testing

Date Information is needed by:

I DO NOT WANT THE FOLLOWING INFORMATION RELEASED:

Mental health treatment

Alcoholism treatment

Drug abuse treatment

HIV/AIDS records

This authorization is effective for one year from the date requested. I understand that I may revoke this authorization at any time, except to the extent that action has already been taken in reliance upon it, by giving written notice to management at Dubuque Neurology and Sleep Medicine, P.C. 2140 John F. Kennedy Road Suite C Dubuque, IA 52002. Telephone 563-583-1558. Facsimile 563-583-0443.

I understand I have the right to inspect the information to be disclosed upon proper notification to and under appropriate conditions established by Dubuque Neurology and Sleep Medicine, P.C.

I understand that my health care and payment for my health care will not be affected if I do not sign this form. I understand that if the organization authorized to receive the information is not a health plan or health care provider; the released information may no longer be protected by federal privacy regulations. I understand this authorization is voluntary.

PROHIBITION OF RE-DISCLOSURE-This form does not authorize re-disclosure of medical information beyond the limits of this content Where information has been disclosed form records protected by federal law for alcohol/drug abuse records or by state law for mental health records, and HIV/AIDS test results, federal requirements (42 C.F.R. Part 2) and state requirements (Iowa Code Ch. 228 & Ch. 141) prohibit further disclosure without the specific written consent of the patient, or as otherwise permitted by such law and/or regulations. A general authorization for release of medical or other information is not sufficient for these purposes. Civil and/or criminal penalties may result from, unauthorized disclosure of alcohol/drug abuse or mental health related information or HIV/AIDS test results.

Dubuque Neurology and Sleep Medicine, P.C.

Available Forms

Authorization to Release Medical Records