Address: 800 Tydings Lane, Havre de Grace, Maryland, 21078, US
Telephone: (800) 799-4673

How would you like this information delivered?*
- Mail
- Email
- Fax
Patients Full Name*
First Last
Date of Birth*
Date Format: MM slash DD slash YYYY
Phone Number*
Fax #
Email
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Dates of Service

• This Authorization form is designed to meet the requirements of federal privacy regulations issued by the Department of Health and Human Services at 42 CFR § 164.508 and the Annotated Code of Maryland, Title 10 Health General Article §§ 4-301 – 4-307. • Federal confidentiality regulations (42 CFR Part 2) prohibits redisclosure of information from alcohol and drug abuse patient records. However, HIPAA requires Ashley, Inc. to notify me of the potential information disclosed pursuant to this authorization might be redisclosed by the recipient and is no longer protect by the federal regulations reference above but may be protected by Maryland law. • This authorization is voluntary. • I understand that if someone is signing as my personal representative, proof of legal authorization to act on my behalf will be required. • This authorization to disclose information may be revoked by me at any time, except to the extent that action has been taken prior to receipt of revocation. To revoke the authorization, I understand that I must notify the HIM department at Ashley, Inc. in writing.
Patient Signature
Date
Date Format: MM slash DD slash YYYY
Personal Representatives Signature (if appropriate)
Date
Date Format: MM slash DD slash YYYY
This authorization will expire one year from the date it is signed unless a shorter time is indicated here:
I have indicated what information should be released:
- Yes
- No
If signature is other than patient, explain your authority to act for the patient: _________________
If there is a question or concern with responding to this authorization, you will be contacted by the HIM department to discuss it. You will be contacted by the HIM department for verification purposes. If you have questions about medical records please email medicalrecords@ashleytreatment.org

Authorization to Disclose Medical Records

Step 1 of 3

Leave a review on Google