Authorization to Use, Disclose, Receive, Send or Portal My Personal Health Information. 

Print, complete then email to ma2@sdcim.com upon completion

Patient Name (Print)___________________________________________DOB_____________________Last 5 SSN_____________________


I hereby authorize my Health Care Providers to disclose any portion or all of my Health information TO:
     Recipient: (circle one)      Dr. Duffee/SDCIM   or   Other locale: (doctor/practice name/agent/agency/portal set up)___________________________

     AT:   (for Dr. Duffee) : Email (please encrypt):  doctor@sdcim.com     or      E-fax: 719-542-3110

     AT:   ( for Other locale) : Email or secure upload site:_________________________________Efax:_________________Phone:_____________

Once Sangre de Cristo Internal Medicine Associates receives or discloses personal health information, the person or organization that possesses it may re-disclose the information upon request. Privacy laws may no longer protect the information.

Items Requested:  circle one:      1) for           or           2) Sent By           SDCIM:

Specific Items requested (check one or fill in other, fees may apply see www.sdcim.com >> medical records):

Portal set up credentials_______
Entire clinical chart_______
Last 5 years of clinical chart_______
Last 1 year of clinical chart_______
Most recent Health summary, all office visits, labs, cxr, ekg, colonscopy, mammo, pap, dexa_______
Other__________________________________________________________________________


Signature of Patient or Legal Representative:__________________________________Date:__________
Print Name of signatory:____________________________________Relationship to patient:__________


For office use only; Date Sent:_____________________________Completed by:___________________

PLEASE MAKE SURE THIS FORM IS RETURNED WITH THE IDENTITY VERIFICATION FORM (for individual requests) OR WITH YOUR OWN PROPERLY EXECUTED CLINIC/AGENCY/PROXY RELEASE (for proxy requests)


ANY PERSONAL HEALTH INFORMATION (phi) IS FOR THE INTENDED RECIPIENT ONLY, IF YOU ARE NOT
THE INTENDED RECIPIENT, PLEASE DELETE AND/OR SECURELY DESTROY THE RELATED PHI
Thanks, SDCIM

8.18.2018