Complete an Authorization to Release Medical Records

Directions: This is a two part assignment. First, in Kinn’s The Medical Assistant Study Guide use the Records Release Authorization to complete Part IV: Releasing Medical Records on page 102. The information on the form should be made up by you. This portion of the assignment is worth 5 points.

Next, in Kinn’s The Medical Assistant textbook, read Procedure 14-2 on page 243 and then use the Informed Consent for Treatment Form to complete. This portion of the assignment is worth 5 points.

Procedure 14-4:  Competency IX.P.IX.3

Part V. Complete an Authorization to Release Medical Records from using your name as the patient.

RECORDS RELEASE AUTHORIZATION

TO_____________________ _____________________________

^{Doctor or Hospital}

_____________________________________________________

                                                                             ^Address

I HEREBY AUTHOIZE AND REQUEST YOU TO RELEASE TO:

ALL RECORDS IN YOUR POSSESSION CONCERNING _____________

________________________________________ILLNESS AND/OR

TREATMENT DURING THE PERIOD FROM ___________TO_______.

NAME_______________________________TELEPHONE_________

ADDRESS_______________________________________________

SIGNATURE______________________________DATE___________

^{(If relative, state relationship)}

WITNESS________________________________DATE___________

I give my consent to Dr. ___________________________________ and assistants,_________________ to perform:

______________________________________________________________________________________________

(Name of treatment/ procedure. Description in lay & medical terms)

I am aware that, during the procedure, other procedures might be needed. I give my consent to do these procedures as needed.

I give my consent to receive anesthesia and/or drugs I may need.  I know that all procedures and anesthetics have risks like stroke, heart attack, respiratory failure and death.  Some other risks are tooth and nerve damage, and skin/soft tissue injury.

I give my consent for blood and/or blood products if I need them.  I know that all blood and blood products can cause allergic response, fever and hives. I k now the blood bank screens donors for infections and diseases like hepatitis and HIV/AIDS, but I am aware there is a risk of infection.

Patient Initials

If I DO NOT want blood or blood products, I will put my initials in this box    

and fill out the “Statement of Refusal for Blood/ Blood Components”

I give my consent for the ­­­­­­­­­­­­­­­­­­____________   facility to use or to dispose of any substance removed as part of my treatment or procedure. The substance might be body fluids, tissues and organs.  I am aware that the substance might be looked at or used in education for other health care providers.  This material will be disposed of using routine methods.

Patient Initials

If I DO NOT want to be told of the risks listed below, I will put my initials in this box.

I know that each person reacts in a different way to treatments and procedures. Therefore, the results cannot be certain.  My questions have been answered about the procedure.  I have been told:

1. The treatment or procedure that my doctors plan to do
2. What to expect from the treatment or procedure (the benefits).
3. The serious risks of this treatment or procedure.  Some of these risks can happen despite all steps                            being taken to prevent them
4. Other types of treatment that could be used.  This includes no treatment.
5. Whether or not the treatment or procedure is uncommon.

Some of the known serious possible risks for the procedure are:

Severe loss of blood, infection, stroke or heart attack that can lead to death or permanent or partial disability,

Other known serious possible risks are:

Patient Initials

I know I can change my mind about the consent at any time before treatment.

I know that I must tell the health care staff caring for me if I change my mind.

Health Care Provider obtaining consent (PRINT NAME & INITIAL)                      SIGNATURE of person giving consent (legally authorized to do so)

DATE SIGNED                       TIME                       AM/PM                                    Relationship to patient (if applicable)

Name of interpreter:                                                                                                 Second witness for telephone consent: