Mountain Valley Medical Clinic
38 Route 11  P.O. Box 310
Londonderry, Vermont 05148-0310
Telephone No: (802)824-6901 • Fax No: (802) 824-3602

Protected Health Information Release Authorization

Full Name: __________________________________    Date of Birth: __________________

Address: ____________________________________    Phone: ________________________

This will authorize Mountain Valley Medical Center (MVMC) to use or disclose my protected

health information to __________________________________________________________________

Address: _____________________________  Phone: _________________ Fax: ___________________

As described below for the following purposes:

______ Complete copy of medical record.

______ Psychotherapy Notes Only (If applicable, no other information may be included in authorization.)

______ Other (describe): _________________________________________________________________

Dates of care included: _____________________________ to ___________________________________

The information authorized for disclosure may relate to [check all that apply}:

______ Mental illness (excluding psychotherapy notes)   _____ HIV related illness  _____ AIDS

_____   Drug or alcohol treatment (further re-disclosure prohibited or governed by 42 CFR Part2)

______ I understand that I may inspect or copy the protected health information described by this authorization.

______ I understand that this authorization may be revoked in writing and delivered to MVMC at any time, although

    revocation will not be effective as to the disclosure of records whose release I have previously authorized,

    or where other action has been taken in reliance on an authorization I have signed.

______ I understand that information used or disclosed pursuant to this authorization could be subject to

    re-disclosure by the recipient and, if so, may not be subject to federal or state law protecting its

    confidentiality.

______    [I understand the {covered entity} shall not condition treatment, payment, or enrollment in the health

    plan or eligibility for benefits on my providing authorization for the requested use or disclosure AND THAT I

    MAY REFUSE TO SIGN THIS AUTHORIZATION.]

_____    [I understand the {covered entity} shall have the opportunity to obtain direct or indirect remuneration in the

    nature of {describe}: _________________________________________________ from {third party}as a

    result of this authorization.]

____________________    _______________________________________

Date        Signature of individual or representative

            _______________________________________

            [Authority or relationship of representative]

***************

EXPIRATION DATE: This authorization will expire on [date or event] ______________________________

(If no date or event is stated, expiration is six months from the date it was signed.)

COPY PROVIDED:  MVMC shall provide a copy of this authorization, when signed, to the subject individual if

requested.